ࡱ> ~a Sbjbj G\M\M\ 8LT4 <2nnnnIl83333333$694i`"II`"`"4nny46)6)6)`"Fnn36)`"36)6)V1@F2n`Bk "R1 34041x);");F2);F2h+ J6)u < 44%^4`"`"`"`"); > : Wisconsin Department of Public Instruction MASTER EDUCATOR ASSESSMENT PROCESS (WMEAP) ASSESSOR NOMINATION PI-WMEAP-0002 (Rev.10-16) Form available at: http://dpi.wi.gov/tepdl/licensing/types/master/wmeap-assessorsINSTRUCTIONS: Return completed form to: WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION ATTN: CHARLENE KOCI TEACHER EDUCATION, PROFESSIONAL DEVELOPMENT AND LICENSING TEAM PO BOX 7841 MADISON, WI 53707-7841Collection of this information is a requirement of PI 34.19(4). *Educator entity numbers can be found on the DPI Educator License Lookup at:  HYPERLINK "http://dpi.wi.gov/tepdl/license-lookup" http://dpi.wi.gov/tepdl/license-lookupINSTRUCTIONS: Type or print legibly. Nominee completes form, attaches documents and forwards to Professional Organization for endorsement. Organization signs form and sends all materials to the department. All sections of form must be completed and nominees must meet all qualification requirements. The state superintendent will make final selection of nominees. Selected nominees will be required to complete training and make a commitment to assess WMEAP applications and portfolios for three years. I. WMEAP ASSESSOR INFORMATIONLegal Name Last, First, Initial  FORMTEXT      Date of Birth Mo./Day/Yr.  FORMTEXT      Phone Area/No.  FORMTEXT      Street Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT   ZIP  FORMTEXT      E-Mail Address  FORMTEXT      Employer  FORMTEXT      Current Education Position  FORMTEXT      Name of License Corresponding to Position  FORMTEXT      DPI Entity No.*  FORMTEXT      Effective Dates of License  FORMTEXT      II. PROFESSIONAL ORGANIZATION ENDORSEMENTCheck Master License for which the nominee qualifies as an assessor: (must be in ONE of listed areas; must be officially employed in that capacity this year; must have a Masters degree related to that license; and must have been employed for a total of five years in that capacity while holding the professional stage license in that specific field).ADMINISTRATIONTEACHINGPUPIL SERVICESSCHOOL BOARD  FORMCHECKBOX  Director of Instruction  FORMCHECKBOX  Director of Special Education/Pupil Services  FORMCHECKBOX  Instructional Library Media Supervisor  FORMCHECKBOX  Instructional/Technology Coordinator  FORMCHECKBOX  Principal  FORMCHECKBOX  Reading Specialist  FORMCHECKBOX  School Business Administrator  FORMCHECKBOX  School District Administrator or Superintendent  FORMCHECKBOX  Career and Technology Education Coordinator FORMCHECKBOX  Adaptive Education  FORMCHECKBOX  Adaptive Physical Education  FORMCHECKBOX  Assistive Technology  FORMCHECKBOX  Speech and Language Pathology  FORMCHECKBOX  Computer Science  FORMCHECKBOX  Dance  FORMCHECKBOX  Psychology  FORMCHECKBOX  Theatre FORMCHECKBOX  School Counselor  FORMCHECKBOX  School Nurse  FORMCHECKBOX  School Psychologist  FORMCHECKBOX  School Social Worker FORMCHECKBOX  School Board MemberOur professional organization nominates the forenamed professional educator as a member of our organization and a qualified WMEAP assessor in the specific license field indicated above.Name of Organization  FORMTEXT      Signature of Organization Officer (III. ASSESSOR QUALIFICATION CRITERIA For administrators, teachers, and pupil services personal ONLY. School board members proceed to PartIV. All criteria must be met and documents attached. FORMCHECKBOX  Documentation of a related masters degreeattach a copy of the Masters or Doctoral Degree or a copy of the official transcript from the IHE which show when the Masters or Doctoral Degree was awarded and in what field.  FORMCHECKBOX  Verification of five years successful experience at the professional educator license stage in the field you will be assessingAttach completed school verification form(s).IV. NOMINEE SIGNATUREUnder oath, I VERIFY-l + ? ~ / 0 d e f wc[h.h55'hR*B*OJQJph&jhR񳯫УА}upu hf6hJhf6h*Mjg#h<Uh<jh<Uj"hfUjhfUhfhhO? hb[h.j!h.U hN@h.jhUmHnHuj~!h.Ujh.Uh.htX hN@htX(lERkdh"$$IfP400**P4 Paf4yt9z $IfgdE$P d$IfgdS0Rkd $$IfP400**P4 Paf4yt9z<>@ $Ifgd*MRkd#$$IfP40x0*x*P4 Paf4yt9z d$IfgdS0 $IfgdE$P,-tg)=kdj%$$IfP40*0**P4 Paf4yt9z ($Ifgd<kd$$$IfP4F` 0*` p`  *P    4 Paf4pyt9z 0+-bcdrstu=>LMNOYZhijȻβȥβȘȋ~qj(hCJUjX(hCJUj'hCJUjp'hCJUj&hCJUhJh9zCJj&hCJU h9zCJjh9zCJUh9z5OJQJh9zhf hf6hJhf6hW:hf56(-<ETbc=YxhXXXXd  $Ifgdd $Ifgdvkd%$$IfP4\^"0*@ *P4 Paf4yt9zdL$Ifgd?, jk~./=>?STbcdtj<,hCJUj+hCJUjl+hCJUj+hCJUj*hCJUj(*hCJUj)hCJU hfh9zj@)hCJU h9zCJjh9zCJUh9zhfh9zCJ-Y~.S0Jmd $Ifgdd $Ifgd#d  $Ifgd   "#$/01?@AIJKYZ[\mn|}~tj|/hCJUj/hCJUj.hCJUjD.hCJUhfh9zCJj-hCJUjt-hCJUj -hCJUh9zj,hCJU h9zCJjh9zCJU hfh9z-  RTVXdvѸѱࣘxnh[nU h<CJj 3hCJU hE$PCJjhE$PCJU h*M56hfh*M56 h9z56h<h*MhndhfCJaJ jhndhfCJaJ hJhfjhUmHnHuj1hfUjhfU hfhfhfh9zOJQJ h9zh9zh9zhfh9zCJy9)d(P$IfgdU!?kd0$$IfP4h0*0**P4 Paf4yt9z $Ifgdxkd/$$IfP4\^"0*@ *P4 Paf4yt9zRVXZ}p} $Ifgd9z $Ifgd*MRkd1$$IfP400**P4 Paf4yt9z $IfgdU!d(($IfgdU! $IfgdE$PtaL ($If^ `gd< $If^ `gd<kd%2$$IfP4KF$0* *P    4 Paf4pyt9zPNQOQSQ_QrQuQQQQQ$R%R&R7R8R9R:RERFRQRRRTRURùzumdh_yhlaJhh0pB6 h6 h0pBCJ jh0pBCJhU!h0pB hkeh0pBhA hO)hhf h ch0pBUh0pBh0pB5h0pBh0pB5;h*MhW:hy0J h<CJju3hCJU hE$PCJjhE$PCJUhyhfhy0J$ $Ifgd*M?kd3$$IfP40*0**P4 Paf4yt9zPQta@!$ & F h(dL$If^`(a$gd#$dL($Ifa$gd<kd<4$$IfP4F 0* *P    4 Paf4pyt9z that all information on this form and accompanying documents are true to the best of my knowledge. Any false statements will result in my being ineligible as a WMEAP assessor. I AGREE as a WMEAP assessor to: attend assessor training for which I will be reimbursed; and, assess new applications and portfolios in my professional field, and, if needed, in the subsequent two years during the summer (one-week time commitment). I understand my travel expenses will be reimbursed by the DPI and I will receive $300 per day honoraria for all work days.Nominee Signature (Date Signed Mo./Day/Yr.      Page PI-0000 PI-0000 Page The state superintendent will select assessors each year from the pool of approved nominees. The number selected is dependent upon the number and fields of the WMEAP applicants and candidates. Training will be required for all new assessors each year. Application approval will take place each spring. Training and portfolio assessment will take place each summer. 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DPISummaryInformation(iDocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q՜.+,D՜.+,d px  FFormsDept. of Public Instruction   NPI-WMEAP-0002 Wisconsin Master Eduator Assessment Process Assessor N