OP2: OPERATION PHYSICS 2010-2011
                                Application for OBR Improving Teacher Quality Program-Supported
                           Otterbein College graduate course: OPERATION PHYSICS (9 qtr. hrs. credit)

                                                Postmark Deadline: March 22, 2010
Please type or print:
Name (official):                                                            SSN:
Name (for name tag):                                                        Birthdate:
Home Address:
City:                                                                                State:             Zip:
Phone:                                                     Email:

School Name:
District (LEA):
City:                                                                    County:                        Zip:
Phone:                                                     Email:
Admin. Name:                                               Ad. Title:

Professional development: Please list experiences (if any) during the last 5 yrs. such as science courses, workshops, conferences,
school or district curriculum planning, text selection, any other science education-related activity or leadership experiences.

Special Characteristics of Your School: Please mention below, or on back of this page, any special characteristics of your school or
student body.

Personal Statement of Interest: I want to learn more about basic physical science concepts and activities for teaching them because:
(Please answer in 50 – 150 words.)

                                                             Teacher Declaration:

IF ACCEPTED* I agree to attend all class sessions to be held on the following days from 8 a.m. to 4 p.m.: June 21-25, 2010, June
28-July 2, 2010; Saturdays Oct. 2, 2010, Nov. 6, 2010, Feb. 5, 2011, and Mar. 5, 2011; and Friday, February 11, 2011.

This project includes a nine (9) quarter-hour graduate course (not a “workshop”) with tuition paid by an OBR grant. There will be
readings, project assignments that require implementation of some of the OP lessons/materials in my classroom, and tests required for
successful completion, a responsibility that I accept.

IF ACCEPTED, I understand that I will have to complete any/all requirements for special non-degree status at Otterbein College. IF
any registration fee is required, I accept responsibility to pay it. (If I am already enrolled in an Otterbein program leading to a degree,
no registration fee will be charged, but some paperwork will be necessary following acceptance into this class.)

Signed _________________________________________________________________________________Date___________

*This application does not guarantee acceptance. We have a limited number of openings. Applicants will be notified of their standing
by April 20, 2010 and will have to complete registration requirements (if any) by June 1, 2010 in order to keep their reservations in
this class.


                                            Acknowledgement of Administrator:
If the teacher named here:___________________________________________________________________________________

is accepted* for this Ohio Board of Regents’ Improving Teacher Quality professional development program, I will send OPERATION
PHYSICS the sum of $175 by June 10, 2010 to add to this teacher’s project budget for classroom science materials. I understand that
my teacher, if accepted for this project, will receive about $650 worth of additional grant-funded lab materials and activity sets for use
in our school.

In addition, I agree to provide the aforementioned teacher a professional development release day on Friday, February 11, 2011 to
attend the Science Education Council of Ohio (SECO) annual conference in conjunction with the OP2: OPERATION PHYSICS

Signed ____________________________________________________________________________Date_____________

Administrator’s name (typed or printed) __________________________________________________________________

Address ____________________________________________________________________________________________


Office telephone: _____________________________________ Fax: _________________________

*This application does not guarantee acceptance. We have a limited number of openings and geographical priorities to comply with requirements of
funding. Applicants can expect to be notified of their standing by April 20, 2010.

Mail completed application to:                            OP2: OPERATION PHYSICS
                                                          c/o Dr. Wendy Sherman Heckler
                                                          Education Department
                                                          Otterbein College
                                                          Westerville, OH 43081

Or FAX application to: Dr. Heckler, OPERATION PHYSICS, (614) 823-3036
For more information, call Dr. Heckler at (614) 823-1840 or e-mail: wshermanheckler@otterbein.edu

                                   FY 2008 PRELIMINARY PARTICIPANT SURVEY
                      For Assessing the Effectiveness of ITQ Professional Development Activities

The following information is needed to complete state and federal reports on our project. It will be aggregated
for the entire class; individual data will be kept strictly confidential. Please provide the following information
about yourself. Use a #2 pencil or a blue or black ballpoint pen to complete this questionnaire. Darken circles
completely and do not stray into adjacent circles. Unless instructed otherwise, darken one circle for each
item. If you are filling out via e-mail, replace circle with an X.

Please create a unique identifier by entering the first two letters of your mother’s maiden name, your birth
month, and your birth day into the grid below. The external evaluator will use the identifier to match survey data
over the project year.

                                                    First 2 Letters of               Your            Your
                                                  Mother’s Maiden Name           Birth Month       Birth Day

                  EXAMPLE                          G                 R            1       2        0       5

            Your Unique Identifier


 P1. What is your current position?
 a) Teacher                                                                                            O
 b) Special Education, Resource or Inclusion Teacher                                                   O
 d) Teacher aide or assistant                                                                          O
 e) Administrator/Supervisor                                                                           O
 f) Other (Specify)                                                                                    O
 P2. What is your gender?
 a) Female                                                                                             O
 b) Male                                                                                               O
 P3. Which of the following categories best describes the way you define your
     racial/ethnic background?
 a) White, non-Hispanic                                                                                O
 b) Black, non-Hispanic                                                                                O
 c) Hispanic                                                                                           O
 d) Asian/Pacific Islander                                                                             O
 e) American Indian/Alaskan Native                                                                     O
 f) Other, not indicated above                                                                         O

P4. What level best describes the grade level you are currently teaching or preparing to teach?
a) PreKindergarten                                                                                  O
b) Primary (K-3)                                                                                    O
c) Intermediate (4-6)                                                                               O
d) Middle (7-8)                                                                                     O
e) High School (9-12)                                                                               O
f) Administrator – Elementary School                                                                O
g) Administrator – Middle School                                                                    O
h) Administrator – High School                                                                      O
i) Administrator/Supervisor (District-wide)                                                         O
j) Other (Specify)                                                                                  O
P5. What type of school best describes where you are currently teaching or preparing to teach?
a) Public School                                                                                    O
b) Private School                                                                                   O
P6. Select the response that best describes the main subject area you are currently teaching or preparing to
a) Self-contained class (teach all or most subjects)                                                O
b) Math only                                                                                        O
c) Science only                                                                                     O
d) Math and Science                                                                                 O
e) Other or Multi-Subject combinations (Specify)                                                    O
f) Not Applicable; Administrator/Supervisor                                                         O
P7. Which of the following influenced you to become involved in this professional
    development program?                                                                   Select all that Apply
a) Applied on my own initiative                                                                     O
b) Participation was required by the school district                                                O
c) School district provided incentives to participate                                               O
d) Encouraged to participate by the project director (Dr. Heckler)                                  O
e) School staff agreed that the program was needed                                                  O
f) Encouraged to attend by a former participant                                                     O
g) Other reason (Specify)                                                                           O
P8. Which of the following types of credit will you receive for participating in this
    program?                                                                               Select all that Apply
a) Graduate credit                                                                                  O
b) Undergraduate credit                                                                             O
c) Credit toward salary increase                                                                    O
d) Credit toward continuing education                                                               O
e) Credit toward certification/licensure                                                            O
f) No credit given                                                                                  O
g) Other (Specify)                                                                                  O
INSTRUCTIONS (P9 – P10): Please write the correct number in each box.
Approximate the number of students in your class(es) who are defined as high-need as
determined by being from families below the poverty line based on census data or by
eligibility for free and reduced price lunches.                                                    Write in Number
Number of high need students in your class(es)
Total number of students in your class(es)

Approximate number of students in your class(es) who are:                                          Write in Number
a) White, non-Hispanic
b) Black, non-Hispanic
c) Hispanic
d) Asian/Pacific Islander
e) American Indian/Alaskan Native
f) Other, not indicated above
g) Total number of students for Race/Ethnicity category (should equal the total
number of students in your class(es) [in question P9])
h) Urban
i) Suburban
j) Rural
k) Total number of students for Location category (should equal the total number of
students in your class(es) [in question P9])
                                       Special Needs
l)    Limited English proficient
m)    Disabled/Handicapped
n)    Migrant
o)    Economically Disadvantaged
p)    Appalachian
q)    Gifted and Talented

Write in the district, county, and school. Mark circle for ratings , district type, and community size.
School District (or Diocese)
County where you teach
School where you teach
                                                                         Continuous          Academic        Academic
                      Distinction      Excellent        Effective       Improvement           Watch         Emergency
District Rating           O                O               O                 O                 O               O
School Rating             O                O               O                 O                 O               O
                                                                                 Less than      Less than    More than
                       Urban        Suburban       Rural                          10,000         50,000       50,000
 District Type           O             O            O           Community Size        O            O            O

P12. To what extent do you agree with each of the
      following statements, as reflected by your                                    Neither
      current ideas and degree of confidence about          Strongly               agree or                    Strongly
      your teaching?                                         Agree     Agree       disagree      Disagree      Disagree
a) I have a good understanding of fundamental core
   content in my discipline                                     O       O              O             O             O
b) I have a good understanding of relating classroom
   activities to Ohio’s Academic Standards                      O       O              O             O             O
c) I have a good understanding of authentic
   assessment methods used to measure student                   O       O              O             O             O
d) I have a good understanding of effective questioning
   techniques and its use in the classroom                      O       O              O             O             O
e) I have a good understanding of the methods
   necessary to teach math and/or science concepts              O       O              O             O             O
f) I believe I am an effective teacher                          O       O              O             O             O
g) I am excited about teaching in my subject area               O       O              O             O             O
h) I am interested in networking with teachers and other
   professionals                                                O       O              O             O             O

P13. Below are seven pairs of statements labeled A through G. Each pair represents opposite ends of a
     continuum in approaches to classroom teaching. After reading a pair of statements, please mark the
     circle that best describes your position on the continuum as it directly relates to your classroom today.

            Classroom interaction consists of                                                    Classroom interaction
            teacher-led lecture with limited                                                involves a dialogue among
            response from students.                                                              teacher and students.
 Pair A              O                      O                    O                    O                       O
            Students generally work in                                                               Students generally
            groups cooperatively.                                                                   work independently.
 Pair B              O                      O                    O                    O                       O
            Instruction focuses on the central ideas of a                      Instruction emphasizes broad coverage
            discipline, covering fewer topics in depth.                                  of information with little depth.
 Pair C              O                      O                    O                    O                       O
            Student role is to receive/recite factual                                    Student role is to apply inquiry
            information and/or to answer questions                                         and problem solving skills to
            using repetitive routines.                                                  discover solutions to problems.
 Pair D              O                      O                    O                    O                       O
            Students generally learn concepts                                       Students generally learn concepts
            and processes using hands-on                                             and processes through readings,
            approaches.                                                                 lectures and demonstrations.
 Pair E              O                      O                    O                    O                       O
            I am generally successful in                                              I find it difficult to encourage the
            encouraging effort and participation                                    efforts and contributions of certain
            among all students.                                                        students or groups of students.
 Pair F              O                      O                    O                    O                       O
            I generally assess students’ progress                        I generally assess students’ progress using
            using conventional methods (e.g., paper                        alternative methods (e.g., open-response
            and pencil tests such as multiple                                      questions, hands-on performance,
            choice, fill-in-the-blank, true/false).                                           portfolios, observation)
 Pair G              O                      O                    O                    O                       O

P14. Please specify the year of your degree and college/university.
                                Year Degree Received                      Name of college/university

a) Bachelor’s

b) Master’s

P15. Please specify a number for each question below.                 Write in Number

a) Number of College Physics courses completed

b) Number of Years of High School Physics

c) Total years of teaching experience

P16. Certification / Licensure (Mark all that apply)

      O    Elementary
      O    Early Childhood
      O    Middle Childhood
      O    Secondary
      O    Other, specify:


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