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 Legal and Theoretical Psychological Services and Current Best Practices in Education and School Psychology
1b. Knowledge of Child and Adolescent Development, Learning Theory, Psychopathology, Cultural Diversity, and Special Education
1c. Setting Goals for Psychology Services That are Appropriate For the Setting and the Diverse Needs of the Students
1d. Designs Interventions and Instructional Supports Using Appropriate Resources
1e. Knowledge of a Variety of Assessment Instruments and Identifies Measures That are Able to Evaluate Educational Problems and Progress
Domain 2- The Environment (circle domain rating)	U	NI	P	E
2a. Creating an Environment of Respect and Rapport
2b. Works Towards Establishing a Positive Culture and Climate Throughout the School
2c. Organizes Physical Space for Assessments, Collaboration, Interventions, Direct Service, and Storage of Materials
2d. Manage Student Behavior Through Collaboration, Behavioral Interventions, and Direct Services
Domain 3 – Delivery of Services (circle domain rating)	U	NI	P	E
3a. Demonstrates the Ability to Effectively Communicate With Students at Their Developmental Level
3b. Utilizes Data-Based Decision Making and Progress-Monitoring to Drive Student Instruction, Interventions, and Services
3c. Implements Evidence-Based Practices and Interventions That Develop Students’ Academic, Social, and Life Skills
3d. Administers and Interprets the Appropriate Observations and/or Assessment Instruments in Order to Determine the Type of Specialized Services That Are Warranted
3e. Demonstrates Flexibility and Responsiveness During Interventions, Assessments, and Direct Services
Domain 4 – Professional Responsibility: (circle domain rating)	U	NI	P	E
4a. Reflects on Services and Practices
4b. Maintaining Accurate Records and Documentation
4c. Communicates Effectively With Parents, School Staff, and Community Agencies
4d. Grows Individually and Collectively as a Professional
4e. Showing Professionalism Including Engaging in Legal, Moral, Ethical, and Professional Practices