Diocese of St. Petersburg - Master Inservice Program
To be Used for All Approved Professional Development Activities and Events
PART I. PARTICIPANT Completion of this form is required for Master Inservice Points to be assigned. Please note that
each independent session of a Conference requires its own Evaluation Form, while a course (i.e. Catechetical Module) is
considered a single activity and needs to be evaluated only at its conclusion.
Event Title: Event Location:
Component Title: Component Number:
Participant Name: Social Security
School: Session Date: Time:
Possible Number of Points: Subject Area for Certification:
Step 1. Please complete grid below.
For each statement below, please check the estent to which you agree:
1-Agree Stongly 2-Agree 3-Disagree 4-Disagree Strongly 5-Does Not Apply 1 2 3 4 5
1. The presentation was well prepared.
2. The materials/handouts were helpful and relevant.
3. The goals/objectives were clear and relevant.
4. This presentation had practical value for me.
5. I would recommend this presentation to others.
Step 2. If your completion of this Component requires additional work such as a paper, project, or faculty presentation,
please indicate the due date for that assignment. (Note: Successful completion of the assignment must be demonstrated
before submitting this form for Point Assignment.) Enter Requirement Due Date:
Step 3. Please complete the following statements:
The single concept/skill from this session that I will use to benefit my students is:
The criterion/criteria by which I will assess the benefit to my students of my attendance at this session are:
If the expected benefit to my students is not observed, I will:
Part II. Local MIP Coordinator
1. For All Participants. Local MIP Coordinator verifies completion of required assignments.
2. For Participants Entered on a Group Attendance Form:
• Be sure the Group Attendance Form is completely filled in.
• Enter Points Earned and your initials in the space provided below.
• Place one copy of this form in the Participant's files, and one in your Local MIP File.
3. For Participants who used an Individual Attendance Form:
• Complete this form, attach it to the Participant's Individual Attendance Form, and file as in #2 above.
Local Coordinator's Initials:
Revised March 2005