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) |

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|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 |

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|SCHOOL |

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|SCHOOL ADDRESS (Street, City, State, Zip Code) |

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|SCHOOL PHONE (Include Area Code) |SCHOOL FAX |

|SUPERINTENDENT INFORMATION |

|NAME |

|Dr. Mr. |

|Ms. Mrs. |

|ADDRESS (Street, City, State, Zip Code) |

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|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) |

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|REFERENCES |

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|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) |

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|Dr. Mr. |

|Ms. Mrs. |

|REFERENCE # 2: NAME, TITLE, EMAIL ADDRESS & PHONE NUMBER (Include Area Code) |

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|Dr. Mr. |

|Ms. Mrs. |

|REFERENCE # 3: NAME, TITLE, EMAIL ADDRESS & PHONE NUMBER (Include Area Code) |

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|Dr. Mr. |

|Ms. Mrs. |

|REFERENCE # 4 (Author of application): NAME, TITLE, MAILING ADDRESS, EMAIL ADDRESS & PHONE NUMBER |

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|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): |

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|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 |

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|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. |

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|RATING #2: |Exemplary educational accomplishments beyond the classroom that provide models of excellence for the profession. Include committees, mentoring,|

| |awards, publications, and presentations. |

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|RATING #3: |Strong, long-range, potential for professional and policy leadership, i.e., predict the educator’s potential to demonstrate leadership in the |

| |profession. |

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|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? |

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|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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