NAME: _____________________________ Employee Number:_______________

Cluster :______ Discipline:___________________ Work Phone: _______________

Activity Title & Description:_______________________________________________

____________________________________________________________________

____________________________________________________________________

Hours of activity:________ Date of activity:_____________

What is the emphasis of this activity? (Check all that apply.)
____ (a) Improvement of teaching.
____ (b) Maintenance of current academic and technical knowledge and skills.
____ (c) In-service training for vocational education and employment preparation programs.
____ (d) Retraining to meet changing institutional needs.
____ (e) Intersegmental exchange programs.
____ (f) Development of innovations in instructional and administrative techniques

and program effectiveness.
____ (g) Computer and technological proficiency programs.
____ (h) Courses and training implementing affirmative action and upward mobility programs.

This activity is a(n): (Check one)
____ College Activity
____ Individual Activity
____ Short Term Teaching
____ Departmental or Interdepartmental Activity
____ Intercampus Activity

Attach substantiating documentation.

Evaluation: To be completed after the activity has been completed. On a scale of 1 (low) to 5 (high) indicate for the activity: Accomplish (Did you accomplish your purpose in undertaking this project?); Value (How valuable to you and your work was this activity?); Repeat (Would you participate in this activity or similar activities again?); Recommend (Would you recommend this activity to others?)

Low High

ACCOMPLISH 1 2 3 4 5
VALUE 1 2 3 4 5
REPEAT 1 2 3 4 5
RECOMMEND 1 2 3 4 5

I, the undersigned, verify that the activity listed on this contract has been undertaken and completed.

Signature______________________________________ Date:_______________

Accepted______________________________________ Date:_______________
for Instructional Improvement Committee