SGC – FORM 4
The Commonwealth of Massachusetts
Department of Elementary and Secondary Education
75 Pleasant Street, Malden, Massachusetts 02148-5023
Telephone: (781) 338-3000
Preservice Performance Assessment for Practicum or Practicum Equivalent
This form is issued pursuant to Educator Licensure and Preparation program Approval Regulations 603CMR 7.00, adopted May
20, 2005 under M.G.L.c. 71s 38G and this form must be completed and filed by all applicants for School Guidance Counselor
Licensure.
Part I –To be completed by the applicant.
Practicum:_
Practicum Equivalent:
1. Legal Name: (print)_
2. SSN:
3. Address:
4. Sponsoring Organization:
Fitchburg State University
5. Practicum Course Number:
Program & Level:
Course Title
Credit Hours:
6. Practicum/Equivalent Site:
8. Total number of practicum clock hours:
M.S. in Counseling / Graduate
_
7: Grade Levels of Students:
Number of clock hours assumed full responsibility in the role:
9. Other Massachusetts licenses held if any:
10. Have any components of the approved program been waived (see Regulations 7.03(1)(b)):
Yes
No
Part II – To be completed by the Program Supervisor
Name:(print)_
Position/Title_
The Applicant completed a practicum/equivalent designed by the Sponsoring organization as partial preparation for the
following license: School Guidance Counselor
Level:
Pre-K-8 or
5-12 (check one)
Part III – To be completed by the Supervising Practitioner
Name: (print)_
School System:
Massachusetts License #:
Position:
License: Initial (w/minimum 3 yrs. experience):
or
Professional:_
_ Title(s) of License(s):
Part IV – Initial 1, 2, and 3.
1. Initial meeting held at which the Professional Standards and the procedures for evaluation were explained to the Applicant.
Date:
Applicant:
_ Program Supervisor:
Supervising Practitioner:
2. Meeting held midway through the practicum at which the Applicant’s progress toward the Professional Standards was discussed.
Date:
Applicant:
Program Supervisor:
Supervising Practitioner:
3. Final meeting held to complete evaluation and to allow Applicant an opportunity to raise questions and make comments.
Date:
Applicant:
Program Supervisor:
Supervising Practitioner:
Part V – Candidate has successfully completed the PPA [Sections: 7.03(2)(a)(4) & 7.04 (2) (b) (4) & 7.11(1)(a)]
Program Supervisor (sign):
Date:
Supervising Practitioner (sign):
Date:
Mediator (if necessary: see 7.04(4))(sign):
Date:
Yes:
No:
Preservice Performance Assessment for Practicum Equivalent
Professional Standards for Professional
Support Personnel-School Guidance Counselor (Pre-K-8; 5-12)
See: Regulations 603 CMR 7.11 (1)(a)
Subject Matter Knowledge:
Rating Scale: 3=Comprehensively meets standard; 2=Acceptably meets standard; 1=Does not meet standard; N/O=Not able to observe
Standard
Evidence
Rating
Justification of Rating*
a. Familiarity with Curriculum
Frameworks and their use in the
advising responsibilities of the
guidance counselor.
b. Understanding and interpretation
Massachusetts Comprehensive
Assessment System (MCAS) and
other academic tests results to
students, teachers, and parents.
c. Psychology of learning.
d. Understanding of the diagnosis
and treatment of learning and
behavior disorders.
3 of 7
*for ratings of 1
Standard
Evidence
Rating
Justification of Rating*
e. Theories of normal and
abnormal intellectual, social, and
emotional development.
f. Knowledge of strategies used for
the prevention and treatment of
substance abuse, physical and sexual
abuse, the spectrum of mental illness,
and violence in PreK-12 students.
g. Philosophy, principles and
practices in school guidance
counseling.
h. Federal, state, municipal, and
school laws and regulations.
4 of 7
*for ratings of 1
Standard
Evidence
Rating
Justification of Rating*
i. Career counseling
j. Resources within the school
system or the community for
referral.
k. Knowledge of statistics,
research design, and research in
guidance counseling.
l. Group counseling and group
leadership.
5 of 7
*for ratings of 1
Standard
Evidence
Rating
Justification of Rating*
m. Development of skills for
consultation with parents, teachers,
and administrators
n. College counseling and use of
college and other post-secondary
resource materials (grades 5-12).
*for ratings of 1
Candidate’s Name:
License:
Program Supervisor (sign):
Date:
Supervising Practitioner (sign):
Date:
6 of 7
MA Department
of Elementary and Secondary Education
Preservice Performance Assessment Form
8/01/13
Professional Standards for Professional
Support Personnel-School Guidance Counselor (Pre-K-8; 5-12)
See: Regulations 603 CMR 7.11 (1)(a)
Candidate’s Name:
License:
Level:
School Guidance Counselor
Pre-K-8
5-12 (check)
.
Summary: Candidate’s Preservice Performance Assessment in the practicum or practicum equivalent is satisfactory: Yes__ or No
Please briefly explain the summary rating (one or two sentences):
Program Supervisor (sign):
Date:
Supervising Practitioner (sign):
Date:
7 of 7
.