Reflective Feedback Form for Courageous
Conversation – August 31, 2004
Your School’s Name:
_____________________________________
(Note: Please complete and return this form to your
principal.)
1. What is your new learning for today?
2. How will today’s work change your practice?
3. How will your work today impact student achievement?
4. How will you know what you did worked?
(over, please)
5. Rate engagement on a scale of 1 to 5 (5 is high)
a. Your own engagement: 1 2 3 4 5
b. Your colleagues’ engagement: 1 2 3 4 5
6. What are the next steps that you, your department, your grade
level and your school should take?
7. I wonder……………..