Title of Activity: ______________________________________________
 

Location of Presentation: ______________________________________
 

Date of Activity: ______________________
 

Duration of Activity (# hours): __________
 

Number of People Attending: ___________
 

List of Schools or Districts Attending:
 
 
 
 
 
 
 

List the specific ways that your school/district supported this on-site professional development activity (i.e. money for supplies/refreshments, release time, attendance encouragement):
 
 
 
 

Name of SPIRAL participant submitting this form ______________________________
 

Signature: _______________________________________ Date: _________________
 
 

Developed by the Child Study Center

Department of Educational and School Psychology

Indiana University of PA