Last Revised: 2/26/2015

Partnership for Educational Leadership

Professional Reference Form

Applicant’s Name:

Mailing Address:

I, the undersigned, hereby voluntarily request that this recommendation be held strictly confidential, and I therefore waive my right to review this recommendation at any time.

Signature Date

Reference

Name of Reference:

E-mail Address:

The above named applicant has selected you to provide a professional recommendation. We would appreciate your assessment of the applicant’s qualifications as a prospective member of the Region 2 Education Service Center’s Partnership for Educational Leadership Program.

Please fill in the following reference and mail to the address below.

Education Service Center, Region 2

209 North Water StreetCorpus Christi, Texas 78401-2599

Your ratings will be compiled with those provided by other professionals to assist in the development of a Professional Proficiency and Certification Plan for the applicants to pursue during the two-year program.

Attention: Certification Program

Mailing Address:

Last Revised: 2/26/2015

Please rate each performance indicator, using the following scale:

5 Exceeds Expectations4 Proficient3 Below Expectations2 Unsatisfactory1 Not Applicable/Do Not Know

Please rate each performance item by circling the appropriate number.

Performance Items RatingEE P BE U NA

1. Plans and schedules work in a timely manner 5 4 3 2 12. Adapts to changing conditions 5 4 3 2 13. Delegates projects/tasks to others 5 4 3 2 14. Builds commitment to plan of action 5 4 3 2 15. Encourages collaboration of all interested groups 5 4 3 2 16. Provides feedback to others for effective performance 5 4 3 2 17. Provides coaching, guidance, or direction to others 5 4 3 2 18. Works well with others in emotional/stressful situations 5 4 3 2 19. Manages conflicts in an effective manner 5 4 3 2 110. Recognizes multicultural sensitivities 5 4 3 2 111. Provides clear, easy to understand directions and presentations 5 4 3 2 112. Utilizes available resources effectively 5 4 3 2 113. Encourages innovation and ongoing improvement 5 4 3 2 114. Exhibits highest standard of professional conduct 5 4 3 2 115. Makes timely and correct decisions based on ethical principles 5 4 3 2 116. Sets priorities to meet program goals 5 4 3 2 117. Identifies and solves problems in an effective manner 5 4 3 2 118. Acts to insure the safety and welfare of others 5 4 3 2 119. Understands human development, learning theory and effective

teaching practices5 4 3 2 1

20. Encourages others to be creative, to use critical thinking, and tocollaboratively solve problems

5 4 3 2 1

21. Assesses curriculum and instruction to insure optimal studentlearning

5 4 3 2 1

22. Provides leadership in developing staff development activities 5 4 3 2 123. Uses self-assessment to identify areas for professional growth 5 4 3 2 124. Seeks to eliminate racism, sexism and other forms of

discrimination5 4 3 2 1

Last Revised: 2/26/2015

25. Understands changing community demographics and impact oncurriculum and instruction

5 4 3 2 1

26. Demonstrates effective communication skills, both written andoral

5 4 3 2 1

27. Practices active listening 5 4 3 2 128. Encourages honest and open communication among groups 5 4 3 2 129. Works with media in sharing educational mission 5 4 3 2 130. Demonstrates positive attitude and enthusiasm 5 4 3 2 1

Please add any comments that might be helpful to us.

How long have you known this applicant?

What position did the applicant then hold?

Signature Position Date