(FLEX ) Instructional Improvement Activity
Claim Form


NAME: _____________________________ Employee Number:_______________

Cluster :______ Discipline:___________________ Work Phone: _______________

Activity Title & Description:_______________________________________________



Hours of activity:________ Date of activity:_____________


What is the emphasis of this activity? (Check all that apply.)

____ (a) Improvement of teaching.

____ (b) Maintenance of current academic and technical knowledge and skills.

____ (c) In-service training for vocational education and employment preparation programs.

____ (d) Retraining to meet changing institutional needs.

____ (e) Intersegmental exchange programs.

____ (f) Development of innovations in instructional and administrative techniques

and program effectiveness.

____ (g) Computer and technological proficiency programs.

____ (h) Courses and training implementing affirmative action and upward mobility programs.


This activity is a(n): (Check one)

____ College Activity
____ Individual Activity
____ Short Term Teaching
____ Departmental or Interdepartmental Activity
____ Intercampus Activity


Attach substantiating documentation.

Evaluation: To be completed after the activity has been completed. On a scale of 1 (low) to 5 (high) indicate for the activity: Accomplish (Did you accomplish your purpose in undertaking this project?); Value (How valuable to you and your work was this activity?); Repeat (Would you participate in this activity or similar activities again?); Recommend (Would you recommend this activity to others?)

Low High (circle one)

ACCOMPLISH 1  2  3  4   5
VALUE  1   2    3   4     5
REPEAT 1   2   3    4    5
RECOMMEND 1   2   3   4   5


I, the undersigned, verify that the activity listed on this contract has been undertaken and completed.


Signature______________________________________ Date:_______________


Accepted______________________________________ Date:_______________