Tennessee Center for the Study and Treatment of Dyslexia

Workshop Request Planning Form

Thank you for contacting the Center regarding professional development for your educators. We look forward to collaborating with you in order to best meet your needs and expectations. In order to best plan for your workshop, please complete and submit this form at least six weeks in advance of your anticipated training date. The majority of the fields below require your response in order for this form to be successfully submitted.

Workshop Request Planning Form

1st Choice of Workshop Date: Please indicate your preferred workshop date & time. Please note: We do not guarantee workshop dates or times until a workshop agreement is completed.(Required)

2nd Choice of Workshop Date: Please indicate a backup workshop date & time. Please note: We do not guarantee workshop dates or times until a workshop agreement is completed.

Name(Required)

First Last

Role: Please describe your role within your organization.

Organization: Please provide the name of the school, district, agency, or organization for which you are requesting a workshop.

Email: Please provide an email address to allow us to contact you.

Phone Number: Please provide a complete phone number (999) 999-9999 to allow us to contact you.

Workshop: Please select the title of the workshop you are requesting.

Other Workshop: If you selected Other Workshop Interest Not Listed above, please provide a description of the workshop you would like the Center for Dyslexia to provide.

Number of Attendees: How many members of your organization will attend this workshop?

Role of Attendees: Please indicate what role within your organization the attendees hold. You may select as many roles as are applicable for attendees to this workshop session by holding the Control Key (or Command Key on a Mac) as you select the roles.

Workshop Motivation: Please share what motivated your request for this workshop.

Knowledge Goal: What specific knowledge do you want educators to have gained from this workshop?

Skills Goal: What specific skills do you want educators to have gained from this workshop?

Reading Curriculum: What is the name of the reading curriculum, program, or approach used in your core (Tier 1) instruction? Please indicate all programs and the grade level at which they are utilized.

Explicit Instruction in Reading Curriculum: Does your core reading program explicitly teach decoding and spelling skills?

Yes

I’m Unsure

Phonological and phonemic awareness Intervention Curriculum: What is the name of the reading intervention curriculum, program, or approach you utilize within your school district for phonological and phonemic awareness? Please indicate all programs and the grade level/setting in which they are utilized.

Decoding & Spelling Intervention Curriculum: What is the name of the reading intervention curriculum, program, or approach you utilize within your school district for decoding and spelling? Please indicate all programs and the grade level/setting in which they are utilized.

Reading Fluency Intervention Curriculum: What is the name of the reading intervention curriculum, program, or approach you utilize within your school district for reading fluency? Please indicate all programs and the grade level/setting in which they are utilized.

Reading Comprehension Intervention Curriculum: What is the name of the reading intervention curriculum, program, or approach you utilize within your school district for reading comprehension? Please indicate all programs and the grade level/setting in which they are utilized.

Elementary Level Universal Screener: What is the name of your universal screener for elementary school? Please provide information by grade level.

Middle School Universal Screener: What is the name of your universal screener for middle school? Please provide information by grade level.

High School Universal Screener: What is the name of your universal screener for high school? Please provide information by grade level.

Elementary Progress Monitoring Instruments: What is the name of your progress monitoring tool for elementary school? Please provide information by grade level.

Middle School Progress Monitoring Instruments: What is the name of your progress monitoring tool for middle school? Please provide information by grade level.

High School Progress Monitoring Instrument: What is the name of your progress monitoring tool for high school? Please provide information by grade level.

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Tennessee Center for the Study and Treatment of Dyslexia

Workshop Request Planning Form