Talent Pool Recommendation Form
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New Jersey Department of Education
2012 Exemplary Elementary Educator Recommendation Form
Directions: Please refer to the Information Sheet prior to completing this form.
|HONOREE INFORMATION |
|NAME |
|Dr. Mr. |
|Ms. Mrs. |
|HOME ADDRESS (Street, City, State, Zip Code) |
| |
|EMAIL ADDRESS |SELECT ONE: |
| |Classroom Teacher |
| |Principal |
| |Other (specify): |
|CLASSROOM TEACHER INFORMATION (Fill out only if recommending a classroom teacher/other) |
|NUMBER OF YEARS IN DISTRICT |NUMBER OF TOTAL YEARS IN EDUCATION |
| |(not just at your school) |
|GRADE LEVEL(S) TAUGHT & POSITION |
|SUBJECT AREA |
|English/Reading/Language Arts Science World Languages (please specify) |
|Mathematics Social Studies Elementary (all subjects) |
|Other (please specify) |
|PRINCIPAL INFORMATION (Fill out only if recommending a principal) |
|NUMBER OF YEARS AS AN ADMINSTRATOR |TOTAL YEARS IN EDUCATION (include years as a teacher & administrator at other |
| |schools) |
|GRADE LEVELS IN THE BUILDING |
|SCHOOL INFORMATION |
|SCHOOL DISTRICT |
| |
|SCHOOL |
| |
|SCHOOL ADDRESS (Street, City, State, Zip Code) |
| |
|SCHOOL PHONE (Include Area Code) |SCHOOL FAX |
|SUPERINTENDENT INFORMATION |
|NAME |
|Dr. Mr. |
|Ms. Mrs. |
|ADDRESS (Street, City, State, Zip Code) |
| |
|EMAIL ADDRESS |PHONE NUMBER (Include Area Code) |
| | |
|PRINCIPAL INFORMATION |
|NAME |
|Dr. Mr. |
|Ms. Mrs. |
|EMAIL ADDRESS |PHONE NUMBER (Include Area Code) |
| | |
|SUPERVISOR INFORMATION (If different than above) |
|SUPERVISOR’S NAME |
|Dr. Mr. |
|Ms. Mrs. |
|EMAIL ADDRESS |PHONE NUMBER (Include Area Code) |
| | |
|REFERENCES |
| |
|Please list the names, titles, email addresses, & phone number for the first three references, other than you; |
|The person completing the application should be listed as the fourth reference; |
|One of the references must be the candidate’s direct supervisor; and |
|The references will be contacted so they should know and work with the educator at the current time and be able to provide additional information that supports the |
|candidate’s nomination. |
|REFERENCE # 1: NAME, TITLE, EMAIL ADDRESS & PHONE NUMBER (Include Area Code) |
| |
|Dr. Mr. |
|Ms. Mrs. |
|REFERENCE # 2: NAME, TITLE, EMAIL ADDRESS & PHONE NUMBER (Include Area Code) |
| |
|Dr. Mr. |
|Ms. Mrs. |
|REFERENCE # 3: NAME, TITLE, EMAIL ADDRESS & PHONE NUMBER (Include Area Code) |
| |
|Dr. Mr. |
|Ms. Mrs. |
|REFERENCE # 4 (Author of application): NAME, TITLE, MAILING ADDRESS, EMAIL ADDRESS & PHONE NUMBER |
| |
|Dr. Mr. |
|Ms. Mrs. |
|BACKGROUND INFORMATION |
|EDUCATION (Please list the most current first) |
|Schools Attended |
|Degree Earned |
|Year of Graduation |
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|Indicate ethnicity of educator being recommended (optional): |
| |
|White Black or African American |
|Asian Native American Indian or Alaska Native |
|Hispanic or Latino Native Hawaiian or Other Pacific Islander |
|Other (please specify) |
|EVALUATION COMPONENT |
| |
|RATE the educator from 1 to 10 (10 being the highest) on the following four (4) criteria & provide a narrative to explain your rating. Be detailed and thorough, with |
|examples whenever possible. Please use as much space as needed. |
|RATING #1: |Exceptional educational talent as evidenced by effective instructional practices and student learning results in the classroom and school. |
| | |
| | |
|RATING #2: |Exemplary educational accomplishments beyond the classroom that provide models of excellence for the profession. Include committees, mentoring,|
| |awards, publications, and presentations. |
| | |
| | |
|RATING #3: |Strong, long-range, potential for professional and policy leadership, i.e., predict the educator’s potential to demonstrate leadership in the |
| |profession. |
| | |
| | |
|RATING #4: |Engaging and inspiring presence that motivates and impacts students, colleagues, and the community. Do students perform at higher levels due to|
| |the educator, pursue certain careers, credit their success to the educator, etc? |
| | |
| | |
|Cite evidence of student achievement gains as a result of the educator’s practices: |
| |
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|Cite any awards the educator has received: |
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|Other comments: |
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