MATHEMATICS AND SCIENCE CENTERS
		    OTHER SERVICES ACTIVITY LOG/EVENT RECORD


OTHER SERVICES (OS) are all services other than Student Services (SS) or
Professional Development (PD).  This form is to be completed by the person
who provides the service.


1. PERSON PROVIDING THE SERVICE: _______________________________

2. TITLE OF ACTIVITY/EVENT: _________________________________

3. DATES: 		4. LOCATION: 			5. CONTACT HOURS:
   _____________   	   ________________________	   _____________


6. SCHOOLS/DISTRICTS INVOLVED:			7. PRIMARY TARGET GROUP:
   (list here, attach list, or indicate "All")	   (check one)
						   ___ Teachers
						   ___ Administrators
						   ___ Parents
						   ___ Community Leaders
						   ___ Mixed
						   ___ Others
							Describe:
8. TOTAL ATTENDANCE: ____				______________________

9. Focus:				10. CENTER INVOLVEMENT/ROLE:
   (Check only those that apply)	   (Check only those that apply)
   ___ Leadership			   ___ Individual/Small Group Consultation
   ___ Professional Development		   ___ Participation in committee work/
   ___ Student Services						task forces
   ___ Curriculum Support		   ___ Leadership role in community event
   ___ Community Involvement		   ___ Presentation/leadership in small
   ___ Resource Clearinghouse					group/committee
   ___ Other				   ___ Collaborations/partnership
   	Describe: 						participation
   	_______________________		   ___ Local/regional planning for M/S/T
					   ___ Other
						Describe: _______________________

11. CONTENT AREA: (Check one)               12. STATEWIDE PROJECT FOCUS:
    ___ Math		___ Science              (Check one if appropriate)
    ___ Technology	___ Combination		___ Algebra for All      
    ___ Other					___ NMSI     
	 Describe: ____________________		___ MMLA     ___ MMSTLC
						___ MSLA     ___ MDE Curriculum
						___ MVU
						___ Other
						    Describe: ________________

13. DESCRIPTION: (Purpose of activity)          FOR OFFICE USE:

						PRIMARY STRATEGIC PLAN CODE:

						______________________________
						OTHER STRATEGIC PLAN CODES:

						______________________________
						ACTIVITY CODE #:

						______________________________

Prepared by SAMPI, Western Michigan University, for 2009-2010 use.