START Effective Practice Leadership Initiative (EPLI)

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START EPLI (Effective Practices Leadership Initiative)

Level 1 Trainer Application

Note: Complete this application electronically and submit to Melissa Kurek

New Applicant Returning Applicant – must update fields*

REQUIREMENTS TO APPLY TO BE A LEVEL 1 TRAINER:
·  Hold a Michigan Department of Education credential;
·  Be employed by a public school system in Michigan;
·  Have at least 3 years of experience working with students with ASD;
·  Possess strong content knowledge of ASD and effective supports for students with ASD;
·  Have knowledge and skills in teaming and problem solving;
·  Have good public speaking skills and willingness to develop these skills;
·  Possess a strong working relationship and credible reputation with colleagues as demonstrated by recommendations.
*Name:
/ *Home/Cell Phone:
*E-mail:
*Are you currently employed by a school system in MI? Yes No
*District / School Name:
School Address:
City: State: Zip Code: School Phone:
*RCN (Regional Collaborative Network): Select your RCN nameCAN4GCACMACCRANGreat Lakes BayKent CANLakesideLEANMACNANOCANSMACSMARTThumb AreaUPANWayneWestMACWIN4Autism
Professional Certification:
/ Job Title:
Professional Discipline:
Provider of Speech & Language / School Psychologist / Social Worker
Occupational Therapist / Special Ed Teacher / General Ed Teacher
Teacher Consultant / Administrator / Other:
Years in current position: / Years working with Students with ASD:
Endorsement in Autism
Yes No / Interdisciplinary Certificate in Autism
Yes No
Competency Area(s): √ the module(s) in which you intend to become an EPLI trainer:
NOTE: You must attend the module(s) presented by START staff.
Positive Behavioral Interventions and Supports Educational Strategies and Supports
You must complete at least 2 additional modules in ONE of the training series listed below to be considered for EPLI. List the modules you attended or plan to attend:
START Intensive Training series at OR RCN Mini Intensive Training series at
List modules attended or plan to attend:

COMPLETE ONLY THE SECTION BELOW ASSOCIATED WITH THE MODULE(S)

FOR WHICH YOU ARE APPLYING TO BECOME A TRAINER.

If you are applying for both modules, complete both sections.

For the following items, indicate your response in the box provided using the scale below:

1 = strongly agree; 2 = agree; 3 = neutral; 4 = disagree; and 5 = strongly disagree

Positive Behavioral Interventions and Supports Module:

1.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I have received extensive training (e.g. university courses, workshops, conferences, etc.) in the areas of PBIS (Positive Behavioral Interventions and Supports), school-wide positive behavioral supports, functional behavioral assessment (FBA) and individual behavior support plan development and I can provide documentation if requested.

2.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I have extensive training and experience implementing effective practices for students with ASD and can provide documentation if requested.

3.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I have been involved in completing more than 5 FBAs for students with ASD and can provide examples if needed.

4.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I have been involved in developing and implementing more than 5 individualized behavioral support plans and can provide examples if needed.

5.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I have extensive experience working with school-based teams to address behavioral issues for students with ASD and can provide documentation if requested.

Educational Strategies and Supports Module Questions:

1.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I strongly advocate that students with ASD should be primarily educated with students who are not disabled.

2.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I have a solid understanding of Least Restrictive Environment and how it pertains to students with ASD.

3.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I have received extensive training (e.g. university courses, workshops, conferences, etc.) in the areas of special educational law, general education curriculum, differentation, and grading and can provide documentation if requested.

4.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I have considerable experience promoting access to general education for students with ASD in my current position and can provide documentation if requested.

5.  Indicate your response1 = Strongly Agree2 = Agree3 = Neutral4 = Disagree5 = Strongly Disagree I have developed numerous ways to differentiate output (e.g. class assignments and projects) for students with ASD so they could access the general education curriculum and general education environments and can provide examples, if needed.

NARRATIVE: You may expand on any of the statements above or provide additional information you believe will support your approval to participate in the EPLI Trainer process.

Name of Supervisor approving your application:

I certify that I meet the specifications and qualifications to be a START Trainer, and all information in this application is accurate to the best of my knowledge.

Signature Date

2

START Project February 2016