Instructional I to instructional II assessment form

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Commonwealth of Pennsylvania


333 Market St., Harrisburg, PA 17126-0333


Applicant’s Last Name First Middle Positions(s) of Employee

District/IU School Evaluator Interview/Conference Date

Directions: This form is used after having reviewed 6 satisfactory semi-annual employee evaluations of the teacher’s performance. All categories in this form must be assessed as well as all sources of evidence provided by the teacher. The evaluator should bear in mind the aspects of teaching for each category and refer to the rubric language. If applicable, record commendations. Finally, assign an overall assessment, sign the form and gain Superintendent’s review and signature.

Category I: Planning/Preparation--Through their knowledge of content and pedagogy skills in planning and preparation, teachers make plans and set goals based on the content to be learned, their knowledge of students and their instructional context. Category I reviews: Knowledge of Content and Pedagogy, Knowledge of Pennsylvania Academic Standards, Knowledge of Students, Selecting Instructional Goals, Designing Coherent Instruction, Assessing Student Learning, Knowledge of Resources, Materials and Technology.

Teacher’s performance demonstrates:

  • In-depth and thorough knowledge of content and pedagogy

  • In-depth and thorough knowledge of Pennsylvania’s Academic Standards

  • In-depth and thorough knowledge of students and how to use this knowledge to inform instruction

  • Clear and appropriate instructional goals that reflect content standards and high expectations for students

  • Thorough awareness of resources, materials, and technology available through the school or district or professional organizations

  • Appropriate and coherent instructional design in which plans for all elements are completely aligned with the instructional goals, have a clear sequence, and include adaptations for individual student needs

  • Appropriate and clear assessments of student learning completely aligned to the instructional goals, and adapted as required for student needs

Sources of Evidence (Check all that apply and include dates, types/titles and number)

  • Lesson/Unit Plans

  • Resources/Material/Technology

  • Assessment Materials

  • Information About Students

Assessment of Category I Factors (Discussion)


Category II: Classroom Environment --Teachers establish and maintain a purposeful and equitable environment for learning, in which

students feel safe, valued, and respected by instituting routines and setting clear expectations for student behavior. Category II reviews:

Teacher Interaction with Students, Establishment of a Learning Environment, Student Interaction.

Teacher’s performance demonstrates:

  • High and clear expectations for student achievement in a challenging and dynamic learning environment, with value placed on high quality student work

  • Significant attention to equitable learning opportunities for students

  • Appropriate and highly respectful interactions between teacher and students and among students

  • Highly effective classroom routines and procedures resulting in effective use of instructional time

  • Clear standards of conduct and highly effective and preventive management of student behavior

  • Safe and skillful organization of physical space, to the extent it is under the control of the teacher, that provides accessibility to learning and to the use of resources, materials, and technology

Sources of Evidence (Check all that apply and include dates, types/titles, and number)

  • Classroom Observations

  • Informal Observations/Visits

  • Teacher Conferences/Interviews

  • Visual Technology

  • Resources/Materials/Technology/Space

  • Other

Assessment of Category II Factors (Discussion)

Category III: Instructional Delivery --Teachers, through their knowledge of content and their skill in delivering instruction, engage

students in learning by using a variety of instructional strategies. Category III reviews: Communications, Questioning and Discussion

Techniques, Engaging Students in Learning, Providing Feedback, Demonstrating Flexibility and Responsiveness.

Teacher’s performance demonstrates:

  • Clear and appropriate communication of procedures and high-quality explanations of the content

  • Highly effective use of different levels of questioning and discussion strategies that encourage most, if not all, students to participate

  • High-level engagement of students in learning and appropriate pacing of instruction

  • Equitable, accurate, and constructive feedback to students on their learning

  • Informed and appropriate use of formal and informal assessments to meet learning goals and to monitor student learning

  • High degree of flexibility and responsiveness in meeting the learning needs of students

Sources of Evidence (Check all that apply and include dates, types/titles, or number)

  • Classroom Observations

  • Informal Observations/Visits

  • Assessment Materials

  • Teacher Conferences/Interviews

  • Student Assignment Worksheets

  • Student Work

  • Instructional Resources/Materials/Technology

  • Other

Assessment of Category III Factors (Discussion)


Category IV: Professionalism--Professionalism is demonstrated through qualities that characterize a professional person in aspects occurring in and beyond the classroom/building. Category IV reviews: Maintaining Clear and Accurate Records, Communication with Families and Students, Contributing to School and District, Developing Professionalism.

Teacher’s performance demonstrates:

    • Efficient and effective system for maintaining accurate and complete records consistent with school or district guidelines

    • Effective communication with families regarding student needs and development

    • Frequent participation in professional development opportunities, consistent application of new learning in the classroom, and sharing of learning with colleagues

    • Full commitment to professional standards

    • Full and active compliance with school and district policies

    • Perceptive reflection on teaching and learning and use of reflection to in future instruction planning

    • Full Knowledge of Professional Code of Conduct

Sources of Evidence (Check all that apply and include dates, types/titles, and number)

  • Teacher Conferences/Interviews

  • Teacher Reflection

  • Observations/Visual Technology

  • Artifacts: Interaction with Family

  • Student Records/Grade Book

  • Progress Reports/Report Cards

  • Parent/School/Community Feedback

  • Artifacts: Professional Development/
    Act 48 Documentation

  • Other

Assessment of Category IV Factors (Discussion)


Teacher’s Name ______________________ Social Security Number ___________________________

I certify that the before named applicant for the period beginning and ending has received an overall assessment that is: (month/day/year) (month/day/year)

_____Satisfactory _____Unsatisfactory

Signature of Principal/Assistant Date

Principal (Assessor)

Signature of District Superintendent or Date LEA Name

I. U. Executive Director

Overall Justification for Assessment

Commendations (optional)

Name of Applicant Signature of Applicant Date


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