I. Program Contact Information

Name of school or program:

School district:

Program address:

City: State/Province:

ZIP/postal code:

Program phone:

Program fax:

Program e-mail address:

Program Web site:

Program Contact Person

Contact name:

Contact title:

Contact address:

City: State/Province:

ZIP/postal code:

Contact phone:

Contact fax:

Contact e-mail:

Name of person nominating the program:

Nominator’s title:

Nominator’s daytime phone:

Nominator’s e-mail address:

II. Program Description

What is the purpose of your program? (maximum 100 words)

Check the statement that best characterizes your program. (Check all that apply.)

Program designed to provide comprehensive education for academically
      accelerated students.

Program designed to promote early college entrance.

Multigrade program designed to accelerate students in areas of talent. (Check all that apply.)
Math/science
Humanities/literature
Social studies/history
Music and/or dance
Performing arts
Visual/graphic arts
Leadership
Other (please specify):

None of the above. The following statement best characterizes my program:

Does your program adhere to any national or state benchmarks or subject area standards?
Yes No

If yes, check all that apply:
National academic and skill standards (examples are at
       http://www.enc.org/reform/fworks/national.htm)
State standards (examples are at http://putwest.boces.org/Standards.html       and http://www.enc.org/reform/fworks/states.html
National benchmarks (examples are at 
     http://www.project2061.org/tools/benchol/bolframe.html)
Goals 2000 (http://www.ed.gov/Speeches/09-1995/913-g2k.html)
Other (please specify):

Type of setting or school:
Public school (pre-K, K-12)
Private school (pre-K, K-12)
University
Other (please specify):

Note: If your program provides ONLY enrichment in the regular classroom, it probably will not be included in the database.

What are your program’s major sources of funding? (Check all that apply.)
State funding
Sponsoring institution
Foundation(s)
Tuition/fees
Business or industry
Not applicable
Other (please specify):

How important is community collaboration to the success of your program?
Critical
Very important
Not very important
Not applicable

What percentage of your SCHOOL’S enrollment is made up of students from culturally/linguistically diverse backgrounds?
100%
75-99%
50-74%
25-49%
<25%
0

What percentage of your PROGRAM’S enrollment is made up of students from culturally/linguistically diverse backgrounds?
100%
75-99%
50-74%
25-49%
<25%
0

What percentage of your SCHOOL’S faculty is made up of individuals from culturally/linguistically diverse backgrounds?
100%
75-99%
50-74%
25-49%
<25%
0

What percentage of your PROGRAM’S faculty is made up of individuals from culturally/linguistically diverse backgrounds?
100%
75-99%
50-74%
25-49%
<25%
0

What percentage of your SCHOOL population is:
Female?
Male?

What percentage of your PROGRAM population is:
Female?
Male?

What percentage of students in your SCHOOL participates in the free/reduced price lunch program? %

What percentage of students in your PROGRAM participates in the free/reduced price lunch program? %

What are the grade levels of students who receive services? (Check all that apply.)
Preschool
Early elementary (K-3)
Late elementary (3-6)
Middle school (6-9)
High school (9-12)
Multi-graded
Other (please specify):

Who provides the services? (Check all that apply.)
Classroom teacher(s)
Resource or itinerant teacher(s)
University faculty
Other (please specify):

What percentage of students in your program are receiving services for giftedness and for a disability? %

Assessment and Identification of Students

What procedures do you use for assessment and identification of eligible students? (Check all that apply.)
Teacher nomination
Peer/self nomination
Parent nomination
Achievement test scores
Ability test scores
Aptitude test scores
IQ test scores
Portfolio assessment
Other (please specify):

What percentage of your students complete the program?
100%
75-99%
50-74%
25-49%
<25%
0

What do students receive upon completion of the program?
University diploma
High school diploma
Not applicable
Other (please specify):

III. Program Effectiveness and Accountability

What criteria or indicators are you using to determine program effectiveness? (Check all that apply.)
Standardized test scores
Course grades
Self-confidence/self-esteem (please indicate instrument/method used)
Product/portfolio review
Stakeholder satisfaction
Percentage of students completing program
Other (please specify):

If you have reports or statistical data concerning the effectiveness of your program, would you be willing to make those available to other educators?
Yes No

IV. Professional Development/Outreach

To whom are you providing training/outreach about your program? (Check all that apply.)
Regular education teachers
Other school personnel
School-level administrators
District-level administrators
Parents
Community/business leaders

Approximately how many people received training/outreach last year?

How do your program staff receive professional development training? (Check all that apply.)
Preservice
Inservice
Off-site classes
Open meetings
Conferences
Other (please specify):

Approximately how many of your staff received professional development training last year?

Does your program have any other important features that were not covered in the above questions?

Please click the SUBMIT button only once. Hitting SUBMIT multiple times results in addition of inaccurate records to the database and may invalidate your program’s data.