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DP Evaluator Form

To MDHSA Diploma Program Evaluators and those applying to be MDHSA Evaluators:

MDHSA would like veteran MDHSA Diploma Program evaluators , new evaluators, those who want to be on a published list, and those who do not desire to be on a published list, to fill in the form below. If you are a veteran evaluator, you do not have to send in your documentation again.

By completing the evaluator form, you will be able to update your contact information yourself from this point forward. You will not have to wait for someone at MDHSA to edit your account if you need your email addressed changed on the published list.  This way your information will always be current. Please do not contact MDHSA to make changes to your account. Only evaluators who do not have e-mail should contact MDHSA to have their information entered by MDHSA.

This will keep your information current and MDHSA will be able to contact you if there are  updates to the program or if there is information you need to know handed down from the PDE.  After you complete the Evaluator form, you will be sent an email with a link and a password to your account. PLEASE SAVE (write it down) this link and password so that you can update your account as needed.

Those who are applying to be MDHSA Evaluators  for the first time should read the  Diploma Guide, the website Diploma Program Evaluators’ section and must mail their credentials to MDHSA BEFORE completing the form below. Please allow a couple days for us to receive it before completing  the form. For your convenience, e-mailed credentials will also be accepted via e-mail at diploma@pa.net.   The subject line should read “Evaluator Credentials-Your Name.”

ALL FIELDS ARE REQUIRED. Fields containing “~” will appear on the published list ONLY if you check the line that says you want your information published. All other information will remain confidential. After you submit this form, it will be approved by MDHSA. Once approved, you will be provided with a password so you can make changes or updates to your profile.

Instructions: For your state use the two letter post office abbreviation (PA).  For non-PA evaluators who evaluate in PA, supply your contact information, but in “county” please put the PA county in which you do most of your evaluations. For dates use 0/0/00. For Phone numbers, please list as one number with no dividers, ie. 7175557777

MDHSA does not discriminate against families on the basis of race, color, national or ethnic origin.

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