MATHEMATICS AND SCIENCE CENTERS
		PROFESSIONAL DEVELOPMENT ACTIVITY LOG/EVENT RECORD


This form, to be completed by the instructor or facilitator/coordinator of the
activity/event, is used for all types of professional development, e.g., workshops
conducted at a central location or in-classroom work with one or more teachers.

1. INSTRUCTOR(S): _______________________________

2. TITLE OF ACTIVITY/EVENT: _________________________ 3. START DATE: _____________

4. LOCATION OF ACTIVITY/EVENT: ______________________ 5. CONTACT HOURS:	__________

6. ATTENDANCE: _____

7. PRIMARY CONTENT AREA: 	 8. PRIMARY TARGET     9. TARGET GRADE LEVEL:
    (Check one)			    GROUP: (Check one)	    (Check one)
    ___ Mathematics		    ___ Teachers	  ___ Pre K
    ___ Science	         	    ___ Administrators	  ___ Elementary
    ___ Technology	 	    ___ Parents/Others	  ___ Elem & Mid/Jr.High
    ___ Other			    ___ Mixed		  ___ Middle/Jr. High
         Describe:		   			  ___ Mid/Jr. & HS
	 ____________________				  ___ High School
	 						  ___ Other Mixed Levels

10. SECONDARY CONTENT AREA:		   11. STATEWIDE PROJECT FOCUS:
     (Check all that apply - optional)		(Check one if appropriate)
     ___ Mathematics			       ___ Algebra for All
     ___ Science			       ___ NMSI
     ___ Technology			       ___ MMLA     ___ MMSTLC
     ___ Other				       ___ MSLA     ___ MDE Curriculum
          Describe:			       ___ MVU       
	  ____________________		       ___ Other
						    Describe:
						    ____________________

12. MATH/SCI PARTNERSHIP GRANT:  ___ Yes    ___ No

13. DISTANCE LEARNING:  ___ Yes    ___ No

14. ONLINE LEARNING (not associated with MVU):  ___ Yes    ___ No

15. DESCRIPTION: (Purpose of activity)

						  FOR OFFICE USE:

						  PRIMARY STRATEGIC PLAN CODES:

						  __________________________

						  OTHER STRATEGIC PLANS:

						  __________________________

					          ACTIVITY CODE #:

						  __________________________


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