SRTS Evaluation Pilot Application 2018

SRTS Evaluation Pilot Application

Thank you for your interest to help us pilot 2 new SRTS evaluation tools. The application should take between 10 - 15 minutes to complete. If you have any questions regarding the pilot please email Jill Chamberlain at jill.chamberlain@bluecrossmn.com or call 651-662-2912.

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* 1. Please provide your contact information

Name

Organization

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Provide a brief description of your experience working on SRTS.

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* 3. Details about the school that may participate in the pilot:

School Name

Address (please include city and county)

Grade levels

Describe your connection with the school

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* 4. What is the school's experience with SRTS?

Does the school have a SRTS Plan or is it part of a district wide SRTS Plan?

What SRTS activities has the school implemented?

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* 5. Contacts for the pilot are required to participate in a training webinar about the evaluation tools. Please mark all dates and times you would be able to attend. Please note, we will select one time and record for future use.

Thursday March 8 11:30 - 1:00PM

Thursday March 8 1:00 - 2:30

Friday March 9 10:00 - 11:30

Friday March 9 11:30 - 1:00

Friday March 9 1:00 - 2:30

Friday March 9 2:00 - 3:30

Monday March 12 9:00 - 10:30

Monday March 12 1:00 - 2:30

Monday March 12 2:00 - 3:30

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* 6. We will be able to complete use of SRTS evaluation tools by April 13

Agree

Disagree - please provide an estimated date of completion:

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* 7. Will you participate in a phone interview with SRTS evaluators about your experience using the evaluation tools?

Agree

Disagree