Cleveland State University
Teacher as a Responsive, Reflective Professional: A Partner in Learning
College of Education and Human Services
Office of Field Services – Special Education Intern Field Experience Record and Evaluation
Form
Intern:
School:
Experience
(PR/ST):
Grade Level(s)/
Subject:
Semester
and Year:
Completed by (print
name and
check role):
Supervisor
/_
Mentor
CTE
*Supervisors Complete:
Date of
Initial Visit
/
/
Date of
Midterm
Triad
/
/
Date of
Final Triad
/
/
*Mentors complete the sections specific to the field; *If you have a split experience, leave the cumulative
column blank; supervisor will complete
Mentors Complete
7 week
15 week
Cumulative
Absences from the field
Tardies in the field
Missed/Late assignments in the field
Weak/Unacceptable assignments in the field
*Supervisors complete the sections specific to the seminar and the cumulative column. If the intern has a
split experience, complete the cumulative columns for both your section and the mentor’s section.
Supervisors Complete
7 week
15 week
Cumulative
Absences from seminar
Tardies in seminar
Missed/Late assignments in seminar
Weak/Unacceptable assignments in seminar
Rev Date: 03/14
Intern’s Name:
Performance Levels: Exemplary (E)
Scores:
4
3.5
Supervisor’s Name:
Proficient (P)
Emerging (M)
3
2.5
2
Unsatisfactory (U)
Not attempted
1
0
Average Domain Scores
Domain A. Organizing Content Knowledge for Student Learning
Average
7
15
Use of student background information for planning instruction (OSTP Standard 1), (CEC 7)
Plans relate to intern’s knowledge of students.
Plans accommodate for needs of English language learners and students with exceptionalities.
Plans vary instruction based on students’ background.
Plans demonstrate cultural competence by incorporating instructional content, resources, and strategies that are responsive to
cultural, linguistic, and gender differences, the interaction of these factors with the disabilities of students. (CEC 3, 6 )
• Plan reflects an understanding of the effects that an exceptional condition can have on an individual’s learning in school and
throughout
life.
(CEC 3) goals and objectives (OSTP Standard 2)
Instructional
A2.
Plans establish clear goals.
Plans establish measurable objectives.
Goals and objectives relate to varied learning styles.
• Goals and objectives establish appropriate expectations for all students and reflect students IEPs as is appropriate. (CEC 7)
Goals and objectives relate to Ohio Academic Content Standards and are aligned with school curriculum for students with
and without disabilities.(CEC 7)
A1.
Content of instructional plans (OSTP Standard 2)
A3.
•
•
•
•
•
A4.
•
•
•
•
A5. •
•
Plans demonstrate correct sequencing of subject matter.
Plans demonstrate accurate content knowledge.
Plans demonstrate cross-disciplinary connections where appropriate.
Plans reflect the students with disabilities IEPs and Transition plans as appropriate (CEC 7)
Plans demonstrate interns ability to develop long-range individualized instructional plans that are anchored in both general
and special curricula (CEC 7)
Intern modifies instructional plans based on ongoing analysis of the learning progress being made by the students. (CEC 7)
Structure of planned activities and materials (OSTP Standards 1.1, 4)
Structure of lesson is developmentally appropriate for students and subject matter.
Activities and materials match with identified instructional goals.
Activities and materials are appropriate for students’ diverse needs and characteristics
Appropriate accommodations and adaptations are planned for students with disabilities that enable them to participate in the
general education curriculum. (CEC 7)
Appropriate
are used
Assessment technologies
(OSTP Standard
5) to support instructional planning and individualized instruction for students with
disabilities
within
the
general
curriculum
7)
Plan includes varied assessment strategies(CEC
to measure
the achievement of instructional goals and objectives. (CEC 8)
Relevant
Special
Education
laws,
evidence
based
Assessment strategies are appropriate for students.practices,
(CEC 8) and other foundational philosophies and theories are reflected in
planning. (CEC 1)
Licensure Specific Items
A6. • Special Education: Development and Characteristics of Learners (CEC 2)
Plan reflects an understanding of the similarities and differences in human development and the
characteristics between and among individuals with and without exceptional learning needs (ELN)
Plan reflects an understanding of how exceptional conditions can interact with the domains of human
development.
Plan reflects an understand of how the experiences of individuals with disabilities can impact the
individual’s ability to learn, interact socially, and live as fulfilled contributing members of the community.
2
Average
7
15
Rev Date: 03/14
Intern’s Name:
Supervisor’s Name:
A7. • Special Education – Instructional Strategies (CEC 4)
• Plans include appropriate evidence-based strategies to individualize instruction for students with
disabilities within the general and special curricula.
• Plans demonstrate Individualized instructional plans that emphasize explicit modeling and efficient guided
practice to assure acquisition and fluency of skills for students with disabilities through maintenance and
generalization.
• Intern plans for development, maintenance and generalization of knowledge and skills across
environments, settings and the lifespan.
• Plans enhance the learning of critical thinking, problem solving, and performance skills of students with
disabilities.
• Intern plans to increase students’ self-awareness, self-management, self-control, self-reliance, and selfesteem.
A8. • Special Education – Language (CEC 6)
• Plans reflect an understanding of typical and atypical language development
• Plans reflect and understanding of the ways exceptional conditions can interact with students’ experience
with and use of language.
• Plans individualize strategies to enhance language development and to teach communication skills.
A9. • Special Education-Collaborative Planning (CEC 7)
• Intern facilitates instructional planning in a collaborative context including the individuals with
exceptionalities, families, professional colleagues, and personnel from other agencies as appropriate.
• Intern develops a variety of individualized transition plans, such as transitions from preschool to
elementary school and from secondary settings to a variety of postsecondary work and learning contexts
as is appropriate for the students with whom he or she is working. (CEC 7)
•
Domain B. Enhancing the Learning Environment
B1.
B2.
B3.
Average
7
15
Fairness to students (OSTP Standard 5)
Intern establishes a climate of courtesy and respect
Intern makes eye contact with students.
Intern shows impartiality by involving all students.
Rapport with students (OSTP Standard 5)
• Intern expresses interest in students and knows students’ names. (CEC 2)
• Intern shows enthusiasm and appropriate tone.
• Intern establishes positive rapport with students.
Intern shows respect for each student, including those with disabilities (CEC 2)
Challenging expectations for learners (OSTP Standard 1)
• Intern encourages students to ask questions.
• Intern provides students with choices in learning.
• Intern encourages students to pursue further learning.
B4.
•
•
•
•
•
•
Classroom management skills (OSTP Standard 5)
Intern states specific, appropriate expectations for classroom behavior and states reasons for expectations.
Intern applies rules consistently and fairly.
Intern maintains students’ attention throughout the lesson.
Intern establishes and/or maintains a consistent classroom routine. (IGC5S6)
Intern promotes positive behavior. (CEC 5)
When necessary, intern can safely intervene with individuals with disabilities in crisis (CEC 5)
3
Rev Date: 03/14
Intern’s Name:
B5.
•
•
•
•
•
•
•
B6. B7. B8. Licensure Specific Items C2.
Special Education - Supports Inclusion (CEC 5)
When given the opportunity, intern helps general education colleagues integrate individuals with
disabilities in regular environments and engage them in meaningful learning activities and interactions. Special Education – Coordinates and Guides Staff (CEC 5)
Intern coordinates all classroom activities and provides guidance and direction to para-educators &
others, such as volunteers & tutors. Communicating goals and procedures (OSTP Standard 4)
Intern makes goals and objectives clear to students.
Intern makes instructional procedures clear to students.
•
•
•
•
•
C5.
Average
7
15
Communicating content (OSTP Standards 2, 4)
• Intern conveys content clearly and accurately.
• Intern uses correct language, spelling, and syntax in verbal and written explanations of content.
• Intern clarifies content for students having difficulty understanding using differentiated instructional strategies. (CEC 4 )
C3.
C4.
Average 7 15 Special Education– Instructional Strategies & Learning Environments (CEC 4, 5)
Intern sets up learning environment to foster the development of students’ self-awareness, selfmanagement, self-control, self-reliance, and self-esteem.
Intern shapes environment to encourage the independence, self-motivation, self-direction, personal
empowerment, and self-advocacy of individuals with ELN.
Intern creates a learning environment that foster cultural understanding, safety, emotional well-being.
Intern creates a learning environment that fosters positive social interactions and active engagement for
all students including those with and without disabilities
Intern uses a variety of non-aversive techniques to control targeted behavior and maintain attention of
students with or without disabilities. (CEC 4)
Domain C. Teaching for Student Learning
C1.
Supervisor’s Name:
Physical environment (OSTP Standard 5)
Intern maintains a safe learning environment. (CEC 5)
Intern uses universal precautions (IGC5)
Intern enhances student learning with bulletin boards/displays of student work.
Intern uses space and materials to vary physical environment to meet students’ needs and instructional goals.
Intern uses evidence-based instructional strategies to modify the learning environments for students with disabilities. (CEC 4)
When possible, intern provides instruction in a community-based setting. (IGC5S1).
Structure and sequence of instructional activities (OSTP Standard 4)
Intern uses lesson structure and sequence that is developmentally appropriate for students and subject matter.
Intern uses a variety of individual and collaborative learning activities to achieve learning goals.
Intern uses appropriate manipulative and instructional materials to support student learning.
Intern uses adaptations and accommodations to support the leaning of students with disabilities (CEC 4)
Intern uses appropriate available technology to support student learning. (CEC 4)
Extending student thinking (OSTP Standards 1, 4)
• Intern structures specific learning activities that encourage students to extend their critical thinking and problem solving.
(CEC 4 )
• Intern recognizes and uses opportunities to help students extend their thinking.
• Intern uses questioning and other interaction strategies to foster students’ understanding and to stimulate creative and critical
thinking.
• Intern allows sufficient wait-time for student response to questions.
• Intern uses responses and errors to guide instructional decisions and to provide feedback to learners. (IGC4S12)
Assessing student understanding (OSTP Standard 3)
4
Rev Date: 03/14
Intern’s Name:
•
•
•
•
•
•
Supervisor’s Name:
Intern uses questioning and a variety of other appropriate assessment strategies to gauge student learning.
Intern correctly interprets students’ verbal and non-verbal cues for levels of understanding.
Plan includes varied assessment strategies to measure the achievement of instructional goals and objectives.
Assessment strategies are appropriate for students.
Intern uses appropriate technologies to support their assessments (CEC 8)
Intern conducts formal and informal assessments of behavior, learning, achievement, and environments to design learning
experiences that support the growth and development of individuals with disabilities. (CEC 8)
C6.
Use of assessment (OSTP Standards 3, 4)
• Intern keeps written documentation of assessments to track student learning over time.
• Intern adjusts instruction/activities based on formative assessment and uses teachable moments to meet students’ needs. (CEC
8)
• Intern monitors students and gives them substantive feedback.
• Intern uses the results of assessments to help to further identify exceptional learning needs and to develop and implement
individualized instructional programs, as well as to adjust instruction in response to ongoing learning progress. (CEC 8)
• Intern uses assessment information to identify supports and adaptations required for individuals with disabilities to access the
general curriculum and to participate in school, system, and statewide assessment programs. (CEC 8)
C7.
Use of time (OSTP Standard 5)
• Instructional materials are ready prior to the lesson.
• Intern uses routines and procedures to maximize instructional time.
• Intern paces the lesson appropriately for the students and content.
Intern makes smooth transitions between instructional activities to maximize instructional time.
Average
7
15
Licensure Specific Items
C8. • Special Ed –Use of evidence-based practice (CEC 4)
C9.
Intern uses evidence-based strategies correctly to promote positive learning results for students with
disabilities in the general and special curricula.
Intern uses strategies that enhance the development of skills for students with disabilities.
Special Education- Instruction for development, maintenance and generalization of skills (CEC 4) Intern works on development, maintenance and generalization of knowledge and skills across
environments, settings and the lifespan.
C10.
Special Education– Instruction for self-control & self-esteem (CEC 4)
Intern works to increase students’ self-awareness, self-management, self-control, self-reliance, and selfesteem
C11. Special Education-Use of AAC (CEC 6)
Intern uses augmentative, alternative and assistive technologies to support and enhance communication of
students with disabilities, when needed
C12. • Special Education – Supports students who are ELL (CEC 6)
Intern matches their communication methods to individual student’s language proficiency and cultural
and linguistic differences.
• Intern provides appropriate adaptations for English language learners and students with exceptionalities.
Intern provides effective language models and uses communication strategies and resources to facilitate
understanding of subject matter for individuals with disabilities whose primary language is not English
C13. • Special Education- Monitoring Progress (CEC 8)
Intern regularly monitors the progress of individuals with disabilities in general and special curricula.
• Intern monitors students’ progress on behavior programs
Intern monitors intra group behavior changes across subjects and activities.
Average
Domain D. Professionalism
7
D1.
Reflection and professional development (OSTP Standard 7)
Intern uses self-reflection to recognize and correct weaknesses.
Intern reflects on student achievement of the learning goals.
Intern uses feedback from prior observations to improve instruction.
D2.
Completion of work in the field (OSTP Standard 7)
5
15
Rev Date: 03/14
Intern’s Name:
D3.
D4.
D5.
Supervisor’s Name:
Intern follows school policies to maintain accurate student records and grades.
Intern performs assigned professional duties in the classroom.
Intern demonstrates initiative in getting involved in the classroom and working with the mentor.
Collaboration (OSTP Standard 6)
Intern requests professional assistance from appropriate sources.
Intern establishes professional rapport with mentor and supervisor.
Intern maintains appropriate oral and written communication with families. (CEC 10)
Professional habits in the field (OSTP Standard 7)
Intern follows school policies.
Intern displays dispositions listed on the CSU List of Student Dispositions (including punctuality, attendance, and appropriate
appearance) in the field.
Intern participates in additional contractual teacher obligations as required by the experience (planning meetings, faculty
meetings, parent-teacher conferences, professional development activities, school functions).
Intern uses appropriate vocabulary and correct grammar/punctuation in verbal and written communication.
Professional habits in seminar (OSTP Standard 5)
Intern displays dispositions listed on the CSU List of Student Dispositions (including punctuality, attendance, and active
participation) in the seminar and with the supervisor.
Intern completes all assignments and submits written work, including portfolio artifacts, in a timely fashion as assigned by
supervisor, seminar leader, or mentor teacher.
Intern uses appropriate vocabulary and correct grammar/punctuation in verbal and written communication.
Average 7
15
Licensure Specific Items
D6. Special Education –Collaborates Effectively with Parents (CEC 1, 2, 10)
Given the opportunity, Intern maintains oral and written communication with families which is appropriate
for their role as a student teacher, and is provided under the supervision of the mentor teacher. (CEC 10)
Interns show an understand how issues of human diversity can impact families, cultures, and schools, and
how these complex human issues can interact with issues in the delivery of special education services.
(CEC 1)
Intern shows an understanding of how the experiences of students with disabilities can impact families.
If given the opportunity under the supervision of the mentor teacher, intern teaches parents appropriate
management techniques to use with their child. (IGC10S3)
D7. Special Education-Collaboration (CEC 10)
Intern routinely and effectively collaborates with other educators, related service providers, and personnel
from community agencies (given the opportunity) in culturally responsive ways.
This collaboration assures that the needs of individuals with disabilities are addressed throughout schooling.
The intern is able to co-plan and co-teach with the general educator. (IGC10K4)
When appropriate, the intern advocates for individuals with disabilities. The intern promotes and advocate
for the learning and well-being of individuals with disabilities across a wide range of settings and a range of
different learning experiences.
Intern serves as a resource to colleagues in understanding the laws and policies relevant to Individuals with
disabilities. D8. Special Education-Collaboration (CEC 10)
Intern uses collaboration to facilitate the successful transitions of individuals with ELN across settings and
services when appropriate. Special Education – Professional and Ethical Practice (CEC 9)
Intern is guided by the profession’s ethical and professional practice standards. Intern attends to legal
matters along with serious professional and ethical considerations related to Special Education.
Intern engages in professional activities and participates in learning communities that benefit individuals
with disabilities, their families, colleagues, and their own professional growth.
Intern views her or himself as a lifelong learner and regularly reflects on and adjusts her or his practice.
Intern is aware of how his or her own and others attitudes, behaviors, and ways of communicating can
influence practice.
Intern actively plans and engages in activities that foster her or his professional growth and keep him or her
current with evidence-based best practices.
Intern knows his or her own limits of practice, and practices within them. D9. 6
Rev Date: 03/14
Intern’s Name:
Supervisor’s Name:
Mentor teachers completing this form: Please note that all interns will receive two mentor observations unless
the mentor teacher is a CTE.
Please record the averages of each domain in the boxes below.
The third box requires an average of domains A-C.
Observations
Date
Domain
A
Domain
B
Observations
Domain
C
A-C
Average
The intern and observer initial to
indicate receipt of observation
write-up
Domain
D
#3*
CTE’s
only
#4*
CTE’s only
#1
#2
Intern:
Observer:
Intern:
Observer:
Intern:
Observer:
Intern:
Observer:
This section is to be completed for the 7-week Triad Conference only.
Midterm Evaluation (student teaching and practicum interns get a numeric grade at midterm):
Grade (circle one): A (4.0)
A- (3.7)
B+ (3.3)
B (3.0)
B-(2.7)
Strengths
C+ (2.3)
C (2.0)
D(1.0)
F(0.0)
Goals for Second Half of Semester
Signatures for Midterm Evaluation (7-week)
Supervisor
Date
Mentor Teacher
Date
Intern
Date
7
Rev Date: 03/14
Intern’s Name:
Supervisor’s Name:
This section is to be completed for the 15-week Triad Conference only
Final Evaluation (practicum interns receive a grade; student teaching interns are satisfactory or unsatisfactory):
Practicum (circle one): A (4.0)
Student Teaching (circle one):
A- (3.7)
B+ (3.3)
B (3.0)
B- (2.7)
C+ (2.3)
Satisfactory
C (2.0)
D (1.0)
F (0.0)
Unsatisfactory
Supervisor (or CTE) will assign final grade based on mentor teacher and supervisor observations, seminar assignments, portfolio
artifacts, and professionalism.
Strengths
Areas for Continued Professional Growth
Signatures for Final Evaluation (15-week triad)
Supervisor
Date
Mentor Teacher
Date
Intern
Date
----------------------------------------------------------------------------------------------------------------------------- -------------------------------------
Honors and Recognition
****Promising Practicum Intern****
**Initial Check here if nominated for Promising Practicum Intern:
Mentor Teacher
_
Supervisor
****Outstanding Student Teacher****
**Initial here if nominated for Outstanding Student Teacher (top 20%): Mentor Teacher
_
Supervisor
8
Rev Date: 03/14