Teacher:	School:

Grade Level/Subject:	Date:

U=Unsatisfactory	NI=Needs Improvement	P=Proficient	E=Excellent

Domain 1 – Planning and preparation (circle domain rating)	U	NI	P	E
1a. Knowledge of Content of Pedagogy, Literature and Current Trends in Library Media Practice and Information Technology
1b. Knowledge of Curriculum as Well as Students/School Community and How the Library Program Can Address Their Needs
1c. Setting Instructional Outcomes for the Library Media Program
1d. Designing a Coherent Library Program and Organizing Physical Space
1e. Developing a Plan to Evaluate Students and the Library Media Program
Domain 2 - The Environment (circle domain rating)	U	NI	P	E
2a. Creating an Environment of Respect and Rapport
2b. Establishing a Culture for Investigation and an Appreciation of Learning and Literature
2c. Establishing and Managing Library Policies/Procedures and Use of Physical Space
2d. Managing Student Behavior
Domain 3 – Delivery of Services (circle domain rating)	U	NI	P	E
3a. Maintaining and Extending the Library Collection in Accordance With the School’s Needs and Within Budget Limitations
3b. Collaborating with Teachers in the Design, Integration and Teaching of Effective Instructional Units and Lessons
3c. Engaging Students in the Appreciation of Literature and in Learning Information Skills
3d. Using Assessment in Instruction and Delivery of Service
3e. Demonstrating Flexibility and Responsiveness
Domain 4 – Professional Responsibilities: (circle domain rating)	U	NI	P	E
4a. Reflecting on Practice
4b. Maintaining Accurate Records
4c. Communicating with the Larger Community
4d. Growing Individually and Collectively as a Professional
4e. Showing Professionalism including Integrity, Ethics, Advocacy and Confidentiality