Applicant Title / Título:
Institution or System / Institución o Sistema:
Preferred edition / Edición de preferencia: [3227]
Have taught an online course in the past three years / ¿Ha enseñado un curso en línea en los pasados tres años?:
Have taken an online course in the past three years / ¿Ha tomado un curso en línea en los pasados tres años?:
Have you been in charge of an instructional technology initiative / ¿Ha liderado alguna iniciativa de tecnología instruccional?:
Have you been in charge of a distance education initiative / ¿Ha liderado alguna iniciativa de educación a distancia?:
Years of experience in Higher Education / Años de experiencia en educación superior:
Gender / Género:
Age Range / Edad:
Are you Hispanic / ¿Es usted hispano?:
Race Category / Raza:
PART II: Education / Educación:
Highest Earned Degree / Grado más alto de educación obtenido:
College/University / Colegio/Universidad:
Field/Major / Campo de estudio/Especialidad:
Other Degrees Earned / Otros grados obtenidos:
PART III: Experience / Experiencia:
Present Responsibilities / Resumen de responsabilidades:
Academic and Professional Distinctions and Honors / Reconocimientos y premios académicos y profesionales:
Civil and Community Activities / Actividades civiles y comunitarias:
Professional Goals / Metas profesionales:
Please explain what you expect to gain by participating in the H-LTLA / Explique lo que espera adquirir al participar en la H-LTLA:
PART IV: Professional References / Referencias profesionales:
Professional Reference #1 (Include name, title, institution, phone, and email) / Referencia profesional #1:
Professional Reference #2 (Include name, title, institution, phone, and email) / Referencia profesional #2:
Professional Reference #3 (Include name, title, institution, phone, and email) / Referencia profesional #3:
Upload a letter from a president, chancellor, or administrator / Carta de recomendación: See the recommendation letter
PART V: Initiative and Mentor / Iniciativa y mentor:
A letter describing a project that you will consider implementing at your campus or organization with the name of the Mentor of your preference. Your Mentor can be different from your references and should be a staff with experience in the area selected. / Una carta que describa un proyecto que considerará implementar en su campus u organización con el nombre del mentor de su preferencia: See the Initiative letter
PART VI: Statement of Purpose / Declaración de Intención: 1. From your perspective, what are the top three issues facing higher education today? Why? (no more than 300 words) / Desde su perspectiva, ¿cuáles son los tres principales problemas que enfrenta la educación superior hoy día? ¿Por qué?:
2. What are your own institution’s priorities and challenges with regard to leveraging instructional technology and distance education for the benefit of the entire organization? (no more than 300 words) / ¿Cuáles son las prioridades y los retos de su institución con respecto al aprovechamiento de la tecnología educativa y la educación a distancia en beneficio de toda la organización?:
3. If have the influence to instill change at your Institution, was one thing you could change, what would that be; and what is the unique aspect of your institution you would like to keep? (no more than 300 words) / Si pudiera influir para lograr algún cambio en su institución, ¿cuál sería? y ¿cuál es el aspecto único de su institución que le gustaría mantener?

Evaluation

Please provide your input for the following candidate application, using a scale from 1 to 3 (based on the rubric and metrics provided for each area):

Applicant name (for your reference): *

Title (for your reference): *

Track of interest (for your reference): *

Part I. Personal Information and Demographic Data

Part I. Personal Information and Demographic Data: Please provide your input using a scale from 1 to 3 with the following metrics: 1 – (Poor: Have not taught or taken an online course, or have not been in charge of instructional technology or a distance education initiative, and have less than 5 years of experience in Higher Ed.); 2- (Good: Have taught or taken at least two online courses, or have been in charge of instructional technology or a distance education initiative, and have between 6 and 10 years of experience in Higher Ed.); 3- (Excellent: Have taught or taken two or more online courses, have been in charge of instructional technology or a distance education initiative, and have between 11 and 20 or more years of experience in Higher Ed.) *

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Part II. Education

Part II. Education: Please provide your input using a scale from 1 to 3 with the following metrics: 1- (Poor: Bachelor’s degree or less than a bachelor’s degree in any academic Field); 2- (Good: Bachelor’s degree in Education with a major related to Learning Technologies or Distance Ed., or a master’s degree in Education); 3- (Excellent: Master or courses towards a doctor degree, or a doctor’s degrees in Education related to Learning Technologies or Distance Ed.) *

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Part III. Experience:

Present Responsibilities, distinctions, and activities: 1- (Poor: Not present responsibilities related to Learning Technologies or Distance Ed., and doesn't have distinctions or activities related to the fields); 2- (Good: Present responsibilities related to Learning Technologies or Distance Ed., and mentioned distinctions or activities related to the fields); 3- (Excellent: Present responsibilities related to management or supervision of Learning Technologies or Distance Ed. initiatives, and mentioned the distinctions or activities related to the fields). *

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Professional Goals: Professional Goals: 1 – (Poor: Goals described are not related to Learning Technologies or Distance Ed. Initiatives); 2 – (Good: Goals described are related to Learning Technologies or Distance Ed. Initiatives); 3 – (Excellent: Goals described are innovative and related to the management or supervision of Learning Technologies or Distance Ed. Initiatives). *

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Please explain what you expect to gain by participating in the H-LTLA: Please explain what you expect to gain by participating in the H-LTLA: 1 – (Poor: Candidate’s expectations are not aligned with the H-LTLA curriculum and competencies); 2 – (Good: Candidate’s expectations are in some way aligned with the H-LTLA curriculum and competencies); 3 – (Excellent: Candidate’s expectations are significantly aligned with the H-LTLA curriculum and competencies) *

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Part IV. Professional References

Part IV. Professional References: Please provide your input using a scale from 1 to 3 with the following metrics: 1 – (Poor: Provided are one or two references and are not related to Learning Technologies or Distance Ed. Faculty or Administrators, and the nomination letter is pending); 2 – (Good: Provided two references and are related to Learning Technologies or Distance Ed. Faculty or Administrators, and included the nomination letter or provided the evidence that is in process); 3 – (Excellent: Provided more than two references and are related to Learning Technologies or Distance Ed. Administrators, and included the nomination letter) *

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Part V. Initiative and Mentor

Part V. Initiative and Mentor: Please provide your input using a scale from 1 to 3 with the following metrics: 1 – (Poor: The candidate’s initiative is unclear or not aligned with the H-LTLA curriculum and competencies, and the mentor does not seem to have experience in the proposed initiative area.); 2 – (Good: The candidate’s initiative is clear and somehow aligned with the H-LTLA curriculum and competencies, and the mentor seems to have some experience in the proposed initiative area.); 3 – (Excellent: The candidate’s initiative is clear and very aligned with the H-LTLA curriculum and competencies, and the mentor seems to have a lot of experience in the proposed initiative area) *

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Part VI. Statement of Purpose:

1. From your perspective, what are the top three issues facing higher education today? Why? Please provide your input using a scale from 1 to 3 with the following metrics: 1 – (Poor: The issues and explanations are not clear or pertinent to the education reality today); 2 – (Good: The issues and explanations are somehow clear or pertinent to the education reality today); 3 – (Excellent: The issues and explanations are very clear and pertinent to the education reality today) *

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2. What are your own institution’s priorities and challenges with regard to leveraging instructional technology and distance education for the benefit of the entire organization? Please provide your input using a scale from 1 to 3 with the following metrics: 1 – (Poor: The priorities and challenges described are not directly related to leveraging instructional technology and distance education); 2 – (Good: The priorities and challenges described are somehow related to leveraging instructional technology and distance education); 3 – (Excellent: The priorities and challenges described are directly related to leveraging instructional technology and distance education.) *

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3. If have the influence to instill change at your Institution, was one thing you could change, what would that be; and what is the unique aspect of your institution you would like to keep? Please provide your input using a scale from 1 to 3 with the following metrics: 1 – (Poor: Only mention one aspect, and is not directly related to a thing that he/she could change or keep at his/her Institution); 2 – (Good: Mention one or two aspects, and are somehow related to a thing that he/she could change or keep at his/her Institution); 3 – (Excellent: Mention both aspects and are related to a thing that he/she could change and keep at his/her Institution.) *

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Name of the Evaluation Board Member *

Evaluation Board Member Comments about the Applicant: Please write your recommendations or additional feedback

Please select the best category that applies to this candidate based on the following criteria

Please select the best category that applies to this candidate based on the following criteria: 1-Beginner: Obtained mostly 1 point in Personal Information and Demographic Data; Education; Present Responsibilities distinctions, and activities; and Initiative and Mentor; but the rest of the categories could score 1, 2 or 3); 2- Intermediate: Obtained mostly 2 points in Personal Information and Demographic Data; Education; Present Responsibilities distinctions, and activities; and Initiative and Mentor; but the rest of the categories could score 1, 2 or 3); 3- Advanced: Obtained mostly 3 points in Personal Information and Demographic Data; Education; Present Responsibilities distinctions, and activities; and Initiative and Mentor; but the rest of the categories could score 1, 2 or 3) *

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If you are human, leave this field blank.

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