HOW LONG HAVE YOU BEEN A CONSULTANT? (CHECK ONE)
DEMOGRAPHIC INFORMATION: (CHECK APPROPRIATE BOXES)
THIS INFORMATION IS COLLECTED FOR STATISTICAL PURPOSES ONLY. SELECTION OF CONSULTANTS IS BASED ON EDUCATIONAL QUALIFICATIONS, EXPERTISE, AVAILABILITY, CULTURAL COMPETENCY, WILLINGNESS TO TRAVEL, FEE, AND A CLIENT’S/ORGANIZATION’S WILLINGNESS TO ACCEPT YOUR CONSULTANT SERVICES
(CHECK ALL THAT APPLY AND FILL IN THE APPROPRIATE BOXES)
IDENTIFY GEOGRAPHICAL AREA AVAILABLE TO WORK IN AND TRAVEL TO.
Eastern Region: CT, DC, DE, MA, MD ME, NH, NJ, NY, PA, PR, RI, VA, WV, VT, and US Virgin Islands.
Southern Region: AL, AR, FL, GA, KY, LA, MS, NC, NM, OK, SC, TN and TX.
Central Region: CO, IA, IL, IN, KS, MI, MN, MO, MT, ND, NE, OH, SD, UT, WI and WY.
Western Region: AK, AZ, CA, HI, ID, NV, OR, WA, and Pacific Basin: American Samoa, Federated States of Micronesia, Guam, Mariana Islands, the Republic of the Marshall Islands and the Republic of Palau.
ARE YOU WILLILNG TO TRAVEL OUTSIDE OF YOUR STATE OF RESIDENCE? yes
IF SO, WHAT LENGTH OF TIME? 1 – 2 nights
3 – 5 nights
6 nights or more
DO YOU HAVE ANY EXPERIENCE WORKING WITH THE FOLLOWING POPULATIONS? (CHECK ALL THAT APPLY)
DO YOU? (CHECK APPROPRIATE BOXES):
AREA OF EXPERTISE AND YEARS OF EXPEREINCE: PLEASE CHECK ALL THAT APPLY AND LIST NUMBER OF YEARS OF EXPERIENCE IN THE IDENTIFIED AREAS OF EXPERTISE.
A: Organizational Infrastructure Development:
B. Evidence Based Interventions and Support Skills Area:
Other Areas of Expertise:
Questionnaire (please briefly answer the questions below):
The questions comprising this pre-screening assessment are designed to gauge your skills, abilities, and expertise as a consultant. Briefly answer each of the following questions. If necessary, you may attach additional documents or pages. Your individual responses will be kept confidential.
1. How did you hear about Educare for Exceptional Children, LLc?
(For example, website posting, newspaper article, friend, Educare for Exceptional Children, LLc Staff, etc.)
2. Please describe your experience with providing capacity educational consulting, professional development, publishing and research.
3. As an EFEC consultant, what would you say are your PRIMARY areas of expertise?
4. What is your experience working in the following areas: (Should you not have experience in a specific area, please indicate “not applicable”.)
5. Please state your fee range.
6. Are you computer and Internet literate? Are you familiar with PowerPoint? If required, would you be able to create a PowerPoint presentation on an assigned topic?
EQUAL OPPORTUNITIES IN EMPLOYMENT CRIMINAL CONVICTION DECLARATION (CONTINUED
I understand and have been provided with the Equal Opportunities in Employment Act in connection with this application. I am confirming that I have no felony charges at the time of this application. I confirm that the information I have provided in this application form (including the Criminal Conviction Declaration section) is correct and complete. I understand and accept that if I knowingly withhold information, or provide false or misleading information, this may result in my application being rejected, or if I am appointed, in my dismissal, and I may be liable to prosecution. I consent to the information I have provided being processed in accordance to the provisions of the 1998 Data Protection Act.
Please upload your resume/CV
Please upload your W-9 Tax Form
EQUAL OPPORTUNITIES AND DATA PROTECTION POLICY
Educare For Exceptional Children, LLc aims to promote equality of opportunity and is committed to treating all applicants for positions fairly and on merit regardless of race, gender, marital status, religion, disability, sexual orientation, age. We undertake not to discriminate unfairly against applicants on the basis of criminal conviction or other information declared.
Criminal Record Declaration
Prior to making a final decision concerning your application, we shall discuss with you any criminal conviction information declared by you that we believe has a bearing on your suitability for the position. If we do not raise this information with you, this is because we do not believe that it should be taken into account. In that event, you remain free to discuss any of that information or any other matter that you wish to raise. As part of assessing your application, we will only take into account relevant criminal record and other information declared.
Data Protection Act 1998
The Data Protection Act 1998 requires us to advise you that we will be processing your personal data. Processing includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act 1998 defines ‘sensitive personal data’ as racial or ethnic origin, political opinions, religious or other beliefs, trade union membership, physical or mental health, sexual life, commission or alleged commission of offences and any proceedings for any offence committed or alleged to have been committed
The information that you provide in the EFEC application form will be processed in accordance with the Data Protection Act 1998 and may be used for the purpose of enquires in relation to the prevention and detection of fraud. Once a decision has been made concerning your appointment, for successful applicants application data will be retained on their personal file, if unsuccessful, the data will be destroyed after 6 months. Application data will be kept securely and in confidence, and access to it will be restricted to designated persons within the Trust who are authorized to view it as a necessary part of their work.