Peer Reviewer Application

1.  Applicant Information

First Name                         Last Name                

Institution  

Mailing Address

City                                    State                                 Zip Code

Email                   

Phone  

FAX     

2.  Accumulated Online Teaching Experience

Number of semesters of online teaching experience:

Course Management Systems you have used (check all that apply):

Blackboard    WebCT    WebTycho    Other

3.  Currency of Online Teaching Experience

I have taught online within the last 18 months

I am teaching online this semester. Indicate semester:

Experience:

Please describe the types of online courses you have taught (e.g. undergraduate, graduate, continuing education, hybrid, etc.).

4.  Training To Teach Online

No formal training

Formal training within my institution

Self-taught early adopter

Other Formal training as stated:

5.   QM Training:

Applying the QM Rubric Training

Date:            

Trainer:        

Location:      

Peer Reviewer Certification Module:

Date:            

Type of Training                          Date                                          Trainer                                        Location

(ex. Peer Reviewer                     1/15/2007                                    Jane Smith                                 Frederick Community College)

6.   Discipline: Please indicate your current and primary area(s) of teaching experience. You must choose from the categories below, but you may add more specific discipline areas in the spaces provided below.

7.  Education

Bachelors        Major   

Masters           Major   

Doctorate         Major   

8.   Reference – Please provide a teaching colleague, chair, or dean who can be contacted as a reference.

Reference Name   

Position                  

Institution             

Email                   

Phone                  

Fax                      

9.  Please verify all information prior to submitting the form. If you need to make any corrections after submission, please begin a new form and only fill in the fields that need to be changed. You will also be required to fill in your name and email to verify the changes.