Instructor:__________________________________________ Date:_________________________

Past Year:__________ Strengths/Needed Improvements
 
 

Action Taken:
 
 

Current Year:__________ Strengths/Needed improvements
 
 

Plan of Action:
 
 

Attach the following documents to this form:

1) Summary of student evaluation data for each course/section

2) Supervisor's evaluation

3) Self-Assessment

________________________________
Supervisor's Signature, Date  

________________________________
Instructor's Signature, Date