Appendix D (TR)

Rev. 4/18/07

JEFFERSON COUNTY EDUCATIONAL SERVICE CENTER CONSORTIUM

LOCAL PROFESSIONAL DEVELOPMENT PLAN

EQUIVALENT OTHER ACTIVITY (EOA) DOCUMENTATION VOUCHER

Treasurers

Name_________________________________________________________________________

EOA Option __________________________ Number of CEUs __________________________

Please indicate the area of concentration related to this EOA.

( ) Concentration 1 ~

( ) Concentration 2 ~

( ) Concentration 3 ~

( ) Concentration 4 ~

From your IPDP, copy the applicable goal. ___________________________________________

______________________________________________________________________________

Write a brief description of the EOA and how it helped you to grow professionally;

include date(s) when activity or portions of the activity was/were performed.

The signature(s) below verify that this report describes the EOA performed in partial fulfillment of my Individual Professional Development Plan (IPDP).

Signature of Participant Date

Attach any publications, copies of certificates, agendas, etc. that could be used for verification or include a signature of verification, and complete participant reflection on the back.

Verification Signature Position Date