Master Teacher of Students Who Are D/HH
Information/Acceptance Form

(use to accept nomination or to update previously submitted info)

Thank you for your willingness to participate in this wonderful Project! Complete the sections below and then simply click on the "Send" button located at the bottom of this form.

Please indicate reason you are submitting this form:
Accepting nomination as Master Teacher.
Am a current Master Teacher confirming participation or updating previously submitted info.

Please indicate whether your have reviewed the short list of initial Master Teacher activities (which can be found on the Master Teacher Project page).
Yes I have and I have no questions.
Yes I have, but I have a question or two; please contact me.
No I haven't but I will do so right away.

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Contact Info

Your name:
Your e-mail address:	A copy of this submission will be sent to the email address given above.
Alternate e-mail address:
Name of your school:
School address

Instructional/Educational Info

How many years have you taught pK-12 students who are d/hh?    

Join Together Project Master Teachers must be currently teaching/in a classroom. Please indicate your status.
    Yes, I am currently teaching/in the classroom.

    No, unfortunately I am not in the classroom this year.

What grade level(s) do you teach this year?    

What age(s) are your students who are d/hh?    

How many students who are d/hh do you teach this year?    

Do you teach any ESL/ELL students?     Yes No

What areas/topics do you primarily teach (e.g., math, science, language)?

Identify the setting(s) in which you work:
Residential School for the Deaf
Oral school for the deaf
Resource room in a general-ed school
Oral classroom in a general-ed school
Self-contained classroom in a general-ed school
Mainstreamed classroom
Itinerant teaching
Other (please specify)    

What method(s) of communication do you use with your students who are d/hh?
American Sign Language (ASL)
Auditory/Oral
Auditory/Verbal
Cued speech
Sign with speech
Total Communication
Other (please specify)    

Do you have National Board Certification?	Select one yes, hold certification in process will begin process soon na/not pursuing certification
Do you have a Science Certification?	Select one yes, hold certification in process will begin process soon na/not pursuing certification
Do you have a Mathematics Certification?	Select one yes, hold certification in process will begin process soon na/not pursuing certification

Please list topic(s) in which you have expertise or provide leadership within your own district (e.g., itinerant teaching, technologies [software or hardware], cochlear implants, parent/teacher relationships).

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Personal Info

Your hearing status:     Select one deaf/Deaf hard of hearing hearing

Race/ethnic background:    

(Note: we ask that you share this information because one Project goal is to increase the nation's number of teacher candidates representing culturally and linguistically diverse backgrounds and we may seek your insights into this issue.)

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Video Conferencing Info

Do you have videoconferencing capabilities at your school?    Select one Yes No, but will have soon No Do not know

Do you have videoconferencing capabilities in your home?    Select one Yes No, but will have soon No Do not know

Which best describes your Internet access at home?    Select one Cable DSL Dial-up Satellite Other Do not have access
    If you indicated Other, describe:

If you do, or will soon, have videoconferencing capabilities at either school or home, please briefly describe.

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Other

If you'd like to share any additional information (e.g., about yourself, your students), feel free to do so here.

If you need any assistance in completing this form, or if you have any questions relating to this Project, please contact Sherry Ernsberger at sernsber@kent.edu.             (Form last updated 2/19/08)