Orange Unified School District Home Hospital Program Home Hospital Teacher Application Complete all components and submit to the Home Hospital Office Name Home Phone Home Address Cell Phone Employee ID number School Current Assignment Teaching Experience (list most recent position first) Date District School Teaching Assignment (Grade/Subject) Teaching Credentials (please list all credential authorizations/HQT Status) Academic Background (list most recent first) Institution Dates Degree Major/Minor List three professional development trainings you have recently attended Training Title Dates Enduring Learning Home Hospital Application 2014 4/17/14 2:47 PM Please answer the questions in the space provided 1. Give an example of how you have differentiated instruction to meet the needs of an individal student or small group of students. 2. Provide an example of how you have collaborated with colleagues to obtain information, curriculum and/or instruction ideas. 3. Identify how you have incorporated technology into your instructional practices or as a parent/student communication tool. 4. Provide an example of systems you have used to communicate learning goals and students progress with parents and students. 5. Give one example of how you have utilized positive reinforcers to motivate students toward academic success. Applicant Statement: I have read and understand the responsibilities of a Home Hospital Teacher within the Orange Unified School District. Applicant’s Signature Date Home Hospital Application 2014 4/17/14 2:47 PM Every application must be accompanied by two references (using this form). One reference must be completed by an Administrator and one by a colleague. Based on personal experiences, rate the candidate on the following characteristics. Return completed forms to the Home Hospital office (located at CDS). Candidate_____________________________________________ Characteristics Excellent Above Average Average Needs to improve No opportunity to judge Ability to work collaboratively with others Ability to reflect and make changes in their instructional practice Ability to complete and submit paperwork in a timely manner—meet deadlines Ability to effectively and clearly communicate ideas verbally and in writing Ability to use creative problem solving Ability to objectively examine situations and provide non-biased feedback Ability to differentiate instruction to meet the diverse needs of students Ability to organize and manage multiple responsibilities Ability to maintain confidentiality and professionalism when working with colleagues The position of Home Hospital Teacher is unique. It is the most critical role of this program. Do you have any reservations or comments that would inform the committee of the quality of this candidate? _________________________________________ Reviewer Name (please print) Home Hospital Application 2014 ______________ Date 4/17/14 2:47 PM Orange Unified School District Home Hospital Teacher Program Agreement I agree to become part of a cadre of Home Hospital Teachers within the Orange Unified School District. I understand that in addition to adhering to the requirements and expectations of the students I will be working with, I will adhere to the expectations for this position as stated in this agreement. I recognize that my participation in this Home Hospital Teacher Program will provide me with eligibility to have no more than three Home Hospital Students placed on my case load if and when deemed appropriate by the district Home Hospital Coordinator in collaboration with Site Administrators. As a Home Hospital Teacher, I agree to: 1. Attend a one‐time only‐4 hour training on the expectations for Home Hospital Teachers. 2. Commit to provide services for the time designated by the Home Hospital Coordinator. 3. Collaborate with colleagues to obtain assignments, curriculum and student learning goals appropriate to the class/courses for each Home Hospital student. 4. Provide confidential support to the student and parent. 5. Score and grade all assignments completed by the Home Hospital Student and communicate these grades within a timely manner. 6. Submit the Home Hospital Teacher Engagement logs to the Home Hospital Department within given timelines. __________________________________________________________________________________ Home Hospital Teacher Signature Date Home Hospital Department File