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1. Serial Number :

2. Name of Teacher & Designation :

3. School in which working :

4. Qualification :
General :
Educational :
5. Date of birth :

6. Date of appointment :

7. Medium of instruction of the school :

8. Mother tongue of the teacher : l

9. Hours of work allotted to the teacher :

10. Subject handled by the teacher :

11. Proficiency of the teacher to teach

Through the Regional language :

(Whether he/she has passed the
Regional Language in the SSLC and
Degree Course(or) passed the
Language test)
12. Remarks :

Signature of the Supervisor

Countersigned:

District Eductional Officer

1. Name of the state from which the
certificate issued :

2. Name of the certificate No. and date :

3. Name of the holder of the certificate :
4 .Authority issuing the certificate :
5. Subject taken in the Post graduate
course whether the candidate is a
holder of B.T.,B.Ed./M.Ed. Certificate :

6. Subject taken in the degree course :

7. Nature of appointment whether temporary
or permanent, if temporary the periods
to be specified :

8. Whether the appointments approved by

the Chief Educational Officer or not,
if not reason may be stated :

9.Whether the teacher is handling the

subject taken in the degree course :

10. The purpose for which the evaluation

is requested :
(Whether it is required for promotion (or)
approval of appointment (or) sanction
of Incentive increment)
The reasons to be specifically stated.

Signature of the Supervisor

Countersigned:

District Eductional Officer