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Disclaimers and Notices
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Please complete all information.
Date: _________________
Name:
_____________________________________________________________________________
(Mr./Mrs./Ms.) (First) (Last)
Home Address:______________________________________________________________________
City: ________________________ State: _________ Zip: ___________
Home Telephone : (____)__________________Home Email: _________________________________
School District: _____________________________________________________________________
School Name:
_______________________________________________________________________
Street:
_____________________________________________________________________________
City: ____________________________ State: New York Zip:
_________________
School Telephone:
(_____)_______________________ Fax ( _
)_______________________
School Email:
_______________________________________________________________________
Principal:
___________________________________________________________________________
Check Region:
q Long Island q New York City q Lower Hudson
q Mid-Hudson q Capital District q North Country/Adirondacks
q Central NY q Western NY q Southern Tier
Race/Ethnicity (check as many as apply)
q Black/African American q Hispanic/Latino American
q Native American q White/Caucasian
q
Asian/Pacific
Islander American
q
Other (specify)
New York State Certifications:
q K-6
q 7-8 Subject area(s): _________________________________________
q 9-12 Subject area(s): _________________________________________
q other Specify area(s): _________________________________________
Education:
B.A./B.S. ____________________ M.A./M.S. __________________ Other ______________
Current Position: ________________________________________________________________
Please indicate the Standard Setting Session(s) you are interested in attending. You must plan on attending all the days for the respective session(s).
q English Language Arts June 5 – 9, 2006 Albany, NY
q Mathematics July 17 – 21, 2006 Albany, NY
Have you worked with The State Education Department before? What experience have you had with test development tasks (i.e. item writing, item review, exam review, standard setting, and range finding?)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Please return this form to the State Education Department by April 24, 2006 for the English Language Arts session and by May 26, 2006 for the Mathematics session. You will be notified if you have been selected to participate. Your response as an e-mail attachment of this form is preferred.
E-mail: wmcquay@mail.nysed.gov
FAX: (518) 474-1989
MAIL: Office of State Assessment
New York State Education Department
Attention: William McQuay
Room 780 EBA
Albany, New York 12234