Teacher Leader Activity Form

OMB Control No.: 1859-0950

Expiration Date:

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Appendix A

U.S. DEPARTMENT OF EDUCATION

Impact Evaluation to Inform the Teacher and School Leader (TSL) Incentive Program

Teacher Leader Activity Form

Mathematica is collecting this weekly activity form, part of the Design of an Impact Evaluation to Inform the Teacher and School Leader (TSL) Incentive Program, for the U.S. Department of Education. This activity form collects information on your teacher leader activities each week, specifically what activities took place, whom you supported and the focus of the activities. If you have any questions about the study or your school’s participation, email us at [STUDY EMAIL]@mathematica-mpr.com.

We would like you to know the following:

• The activity form takes about 10 minutes to complete each week.

• Your answers will be completely confidential; no information that identifies you, your school, or your district will be reported. Your responses are protected from disclosure per the policies and procedures required by the Education Sciences Reform Act of 2002, Title I, Part E, Section 183. Mathematica will present the information collected as part of this study in an aggregate form and will not associate responses to any of the people who participate. We will not provide information that identifies you, your school, or your district to anyone outside the study team except as required by law. Your responses will be used only for statistical purposes. Any willful disclosure of such information for nonstatistical purposes, without the informed consent of the respondent, is a class E felony.

• The activity form is voluntary, but your response is critical for producing valid and reliable data. You may skip any questions you do not wish to answer; however, we hope that you answer as many questions as you can. Your answers to questions will not affect your job or any hiring decisions now or in the future and will only be shared with the Mathematica study team (they will not be shared with anyone from your school or district).

• Participation in the activity form does not pose any special risks to you as a respondent other than accidental disclosure of information. Mathematica has safeguards in place to ensure respondents’ confidentiality, including restricted access to survey data and separating identifying information such as teacher and school names from survey responses. All Mathematica staff sign a confidentiality pledge, and all staff with access to identifiable study data have received clearance from the U.S. Department of Education and are subject to severe legal consequences for any breach of confidentiality. Any data that identifies you will be destroyed at the end of the study. If you have any questions about your rights as a research volunteer, contact HML IRB toll free at 1-800-xxx-xxxx and reference IRB number xxxxxxxxxx.

Click here to proceed if you have read and understand the above statements and agree to participate in the activity form.

If you would like a copy of this disclosure statement, please contact Eric Zeidman at ezeidman@mathematica-mpr.com or xxx-xxx-xxxxx.

This evaluation is authorized by Title II sections 2001-2002 and Title VIII section 8042 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 6301 et. seq.) as amended by the Every Student Succeeds Act (ESSA).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1850-0950. The time required to complete this information collection is estimated to average 10 minutes, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to U.S. Department of Education, Washington, DC 20202. If you have comments or concerns regarding the content or the status of your individual submission of this form, write directly to U.S. Department of Education, Institute of Education Sciences, 550 12th Street, SW, Washington, DC 20202.

Teacher Leader Activity Form

[To be completed weekly as an electronic form – note that all red text is for organization and review of document and will not display on the electronic form]

Teacher leader activity checklist form, week of		(Select current reporting week: ex. Week of 2/1/21 – 2/5/21)
Section 1: Teacher Leader Information
<Teacher leader name to auto-populate>	Your school’s name: (select from list – will only need to actively select first time and then will auto-populate in future weeks for any needed updates. List of schools will be limited to those in the teacher leader’s district) ☐ School A ☐ School B ☐ School C ☐ School D		Grade level(s) you teach directly (not grades in which you support other teachers): (select from list -- will only need to actively select first time and then will auto-populate in future weeks for any needed updates) ☐ 3 ☐ 4 ☐ 5 ☐ 6 ☐ Other: (Write in response)	Subject(s) you teach directly (not subjects in which you support other teachers): (select from list -- will only need to actively select first time and then will auto-populate in future weeks for any needed updates) ☐ Mathematics ☐ English language arts (including writing or reading) ☐ Social studies ☐ Science ☐ Other: (Write in response)

Section 2: Summary of Teacher Leader Activities for this Week

Section 2.1 Engagement in teacher leader role

1. Did you spend time on any activities this week related to your responsibilities as a teacher leader (for example, preparing to support teachers, directly supporting teachers, or any trainings or meetings)?

☐ Yes (If so, move on to section 2.2)

☐ No (If so, move on to question 2)

2. What is the primary reason you didn’t spend time on any teacher leader activities this week?

☐ I was absent or school was closed for the whole week.

☐ I was absent or school was closed for part of the week, and I didn’t have enough time to work on teacher leader activities in the remaining time.

☐ I was in school all week, but I had to spend my designated time set aside from classroom instruction for teacher leader activities on other responsibilities (e.g. attending professional development, covering another teacher’s classroom, supervising students).

☐ I was in school all week, but I didn’t have any designated time set aside from classroom instruction for teacher leader activities this week.

☐ Other reason not listed (please describe briefly):

No additional questions - form is complete for this week

Section 2.2 Summary of how time was spent

1. How did you spend your time this week as a teacher leader? Include any time spent during school hours and outside of school hours. Select all that apply.

☐ Prepared for supporting other teachers at your school

[If selected] How much time did you spend preparing to support other teachers? (Select # of hours or minutes from drop down) SHOW RUNNING TOTAL OF ALL REPORTED TIME UNDER EACH INDIVIDUAL FIELD

☐ Provided individualized (one-on-one) coaching to other teachers at your school (Coaching includes observing a class, providing feedback, and other types of instructional support such as co-teaching, modeling a practice, and providing resources to support a teacher’s instruction.)

[If selected] How much time did you spend providing individualized coaching? (Select # of hours or minutes from drop down) SHOW RUNNING TOTAL OF ALL REPORTED TIME UNDER EACH INDIVIDUAL FIELD

☐ Provided support to other teachers at your school in a small group or team setting (for example, led professional learning community or PLC)

[If selected] How much time did you spend providing support in a small group or team setting? (Select # of hours or minutes from drop down) SHOW RUNNING TOTAL OF ALL REPORTED TIME UNDER EACH INDIVIDUAL FIELD

☐ Provided support for school- or district-level professional development (do not include individualized coaching or support in a small group or team setting already selected) SHOW RUNNING TOTAL OF ALL REPORTED TIME UNDER EACH INDIVIDUAL FIELD

[If selected] How much time did you spend providing this type of support? (Select # of hours or minutes from drop down) SHOW RUNNING TOTAL OF ALL REPORTED TIME UNDER EACH INDIVIDUAL FIELD

☐ Communicated with your principal about issues related to your teacher leader role (for example, about a debrief with a teacher or the focus of support)

[If selected] How much time did you spend communicating with your principal? (Select # of hours or minutes from drop down) SHOW RUNNING TOTAL OF ALL REPORTED TIME UNDER EACH INDIVIDUAL FIELD

☐ Participated in a meeting to improve your skills as a teacher leader (for example, attended a formal training or met informally with other teacher leaders; do not include meetings with your principal)

[If selected] How much time did you spend in meetings with others to improve your skills as a teacher leader? (Select # of hours or minutes from drop down) SHOW RUNNING TOTAL OF ALL REPORTED TIME UNDER EACH INDIVIDUAL FIELD

☐ Other teacher leader activities not listed (please describe briefly):

[If selected] How much time did you spend on other activities? (Select # of hours or minutes from drop down) SHOW RUNNING TOTAL OF ALL REPORTED TIME UNDER EACH INDIVIDUAL FIELD

2. Based on the time you reported for each activity, you spent <fill total of Q1 responses> this week on teacher leader activities? If this is not accurate, please adjust your prior responses to reflect all of your teacher leader time.

3. How much of the <fill # of hours or minutes from Q2> you spent this week on teacher leader activities occurred during your designated time set aside from classroom instruction for teacher leader activities? Select zero if you did not have any designated time set aside this week.

• The amount of time (# hours/minutes) that occurred during designated set aside time: (Select # of hours or minutes from drop down -- with zero as an option)

4. How much of the <fill # of hours or minutes from Q2> you spent this week on teacher leader activities occurred outside of school hours?

• The amount of time (# hours/minutes) that occurred outside of school hours: (Select # of hours or minutes from drop down -- with zero as an option)

Section 3: Summary of Teacher Leader Individualized (One-on-One) Coaching for Teachers

[Complete Section 3 if ‘Provided individualized (one-on-one) coaching’ was selected in Section 2.2, Q1]

Section 3.1 Summary of teachers supported

1. Which of the following teachers did you provide individualized (one-on-one) coaching to this week? Coaching includes observing a class, providing feedback, and other types of instructional support such as co-teaching, modeling a practice, and providing resources to support a teacher’s instruction.

Select the names of teachers in your school you provided individualized (one-on-one) coaching to this week. (Enter any names of teachers not listed.)

Section 3.2a Detail on individualized (one-on-one) coaching provided for each teacher

Teacher # 1: <Teacher name filled by software>

1. What types of individualized (one-on-one) coaching did you provide to support <teacher name> this week? Select all that apply from the following coaching activities that most closely describe the coaching you provided this week.

☐ Observed <teacher name>’s classroom instruction

☐ Met with <teacher name>to provide feedback based on a classroom observation

☐ Provided written feedback to <teacher name>based on a classroom observation

☐ Helped plan an action step that <teacher name>could use to improve his or her teaching

☐ Co-taught a lesson with <teacher name>

☐ Modeled an instructional practice for <teacher name>

☐ Helped <teacher name>with lesson planning

☐ Supported <teacher name>in practicing a lesson

☐ Other types of individualized (one-on-one) coaching not listed: Please write in other types of coaching provided

2. Which of the following aspects of teaching did the individualized (one-on-one) coaching primarily focus on with <teacher name> this week? Select all that apply from the following list that most closely describe the primary focus of the coaching.

☐ Managing student behavior (for example, expectations for student behavior, applying consequences appropriately)

☐ Managing instructional time (for example, transitioning from one activity to another)

☐ Developing effective lessons (for example, aligning lesson plans with standards, practicing a lesson, reviewing resources on evidence-based practices)

☐ Improving pedagogy (for example, setting appropriate learning goals, reteaching difficult concepts)

☐ Personalizing or differentiating instruction (for example, grouping students by readiness)

☐ Using student data to inform instruction (for example, reviewing student data, how to improve instruction based on data)

☐ Communicating student progress with students

☐ Communicating student progress with students’ families

☐ Improving collaboration with other teachers

☐ Other focus not listed: Please write in a description of other areas of focus

Section 3.2b Detail on individualized (one-on-one) coaching provided for each teacher

(Same items as 3.2a for next teacher; repeat for as many teachers selected)

Section 4: Summary of Teacher Leader Support for Small Groups of Teachers

[Complete Section 4 if ‘Provided support to other teachers at your school in a small group or team setting’ was selected in Section 2.2, Q1]

1. Which of the following aspects of teaching was a primary focus of the support you provided to other teachers at your school in a small group or team setting this week? Select all that apply from the following list that most closely describe the primary focus of the support.

☐ Managing student behavior (for example, expectations for student behavior, applying consequences appropriately)

☐ Managing instructional time (for example, transitioning from one activity to another)

☐ Developing lessons (for example, aligning lesson plans with standards, practicing a lesson, reviewing resources on evidence-based practices)

☐ Improving pedagogy (for example, setting appropriate learning goals, reteaching difficult concepts)

☐ Personalizing or differentiating instruction (for example, grouping students by readiness)

☐ Using student data to inform instruction (for example, reviewing student data, how to improve instruction based on data)

☐ Communicating student progress with students

☐ Communicating student progress with students’ families

☐ Improving collaboration with other teachers

☐ Other focus not listed: Please write in a description of other areas of focus