School-Based Internship Supervisory Materials
Part 2: Forms (Word 2007)
Contents
Daily/Weekly Student Teaching Analysis ......................................................................................... 2
PDE Form 430A ................................................................................................................................ 3
PDE 430 ............................................................................................................................................. 7
PDE Competencies for the Pre-field and Internship Experiences ................................................... 12
Additional Signature Page.......................................................................................................................... 18
Invoice for In-State (PA only) Supervisors ..................................................................................... 19
Daily/Weekly Student Teaching Analysis
Student Teacher:
School placement supervisor:
Date:
1) Your best teaching skills were demonstrated with the following students/in the
following areas:
2) Areas that need improvement or general suggestions for the following day/week:
3) Specific goals for the next day/week are:
___________________________
School placement supervisor
This is a prototype--feel free to modify this form to suit your needs—
2
PDE Form 430A
(Please complete separate forms for Midterm and Final Evaluations)
Student:
Midterm Review
Category I: Planning and Preparation
Lesson Unit Plans: Types Titles and Numbers
Resources/Materials/Technology
Assessment Materials
Information About Students
Student Teacher Interviews
Classroom Observations
Resource Documents
Other
3
Final Review
Category II: Classroom Environment
Classroom Observations
Informal Observations/Visits
Student Teacher/Candidate Interviews
Visual Technology
Resources/Materials/Technology/Space
Other
4
Category III: Instructional Delivery
Classroom Observations
Informal Observations
Assessment Materials
Student Teacher /Candidate Interviews
Student Assignment Sheets
Student Work
Instructional Resources/Materials/Technology
Other
5
Category IV: Professionalism
Teacher Conferences/Interviews
Observations/Visual Technology
Artifacts/Interaction with Family
Student Records /Grade book
Progress Reports/Report Cards
Parent/School/Community Feedback
Artifact Professional Development/Act 48 Documentation
Perceptive Use of Teaching/Learning Reflections
Other:
6
PDE 430
Pennsylvania Statewide Evaluation Form for Student Professional Knowledge and Practice
(Please complete separate forms for Midterm and Final Evaluations)
Student/Candidate’s Last Name
First
Middle
Social Security Number
Speech-Language Pathology Services
Subject(s) Taught
Grade Level (enter
grades covered)
This form is to serve as a permanent record of a student teacher/candidate’s professional performance
evaluation during a specific time period, based on specific criteria. This form must be used at least twice
during the 12-week (minimum) student teaching experience.
PERFORMANCE EVALUATION
Directions: Examine all sources of evidence provided by the student teacher/candidate and bear in mind the aspects of
teaching for each of the four categories used in this form. Check the appropriate aspects of student teaching, and
indicate the sources of evidence used to determine the evaluation of the results in each category. Assign an evaluation
for each of the four categories and then assign an overall evaluation of performance. Sign the form and gain the
signature of the student teacher.
Category I: Planning and Preparation – Student teacher/candidate demonstrates thorough knowledge of
content and pedagogical skills in planning and preparation. Student teacher makes plans and sets goals based
on the content to be taught/learned, knowledge of assigned students, and the instructional context.
Alignment: 354.33. (1)(i)(A), (B), (C), (G), (H)
Student Teacher/Candidate’s performance appropriately demonstrates:
Knowledge of content
Knowledge of pedagogy
Knowledge of Pennsylvania’s K-12 Academic Standards
Knowledge of students and how to use this knowledge to impart instruction
Use of resources, materials, or technology available through the school or district
Instructional goals that show a recognizable sequence with adaptations for individual student needs
Assessments of student learning aligned to the instructional goals and adapted as required for student needs
Use of educational psychological principles/theories in the construction of lesson plans and setting instructional goals
Sources of Evidence (Check all that apply)
Lesson/Unit Plans
Resources/Materials/Technology
Assessment Materials
Information About Students
(Including IEP’s)
Exemplary 3 Points
Category
Criteria for Rating
Student Teacher Interviews
Classroom Observations
Resource Documents
Other
(Distinguished)
Superior 2 Points
(Proficient)
The candidate consistently
and thoroughly
demonstrates indicators
of performance.
The candidate usually
and extensively
demonstrates indicators
of performance.
Rating
(Indicate √)
Justification for Evaluation
7
Satisfactory 1 Point
(Basic but Experience and
Improvement Needed)
The candidate sometimes
and adequately
demonstrates indicators
of performance.
Unsatisfactory 0 Points
(Not trying/Poor Attitude/
Lack of Essential Skills)
The candidate rarely or
never and inappropriately
or superficially
demonstrates indicators of
performance.
Student/Candidate’s Last Name
First
Middle
Social Security Number
Category II: Classroom Environment – Student teacher/candidate establishes and maintains a purposeful and
equitable environment for learning, in which students feel safe, valued, and respected, by instituting routines
and setting clear expectations for student behavior.
Alignment: 354.33. (1)(i)(E), (B)
Student Teacher/Candidate’s performance appropriately demonstrates:
Expectations for student achievement with value placed on the quality of student work
Attention to equitable learning opportunities for students
Appropriate interactions between teacher and students and among students
Effective classroom routines and procedures resulting in little or no loss of instructional time
Clear standards of conduct and effective management of student behavior
Appropriate attention given to safety in the classroom to the extent that it is under the control of the student teacher
Ability to establish and maintain rapport with students
Sources of Evidence (Check all that apply)
Classroom Observations
Informal Observations/Visits
Student Teacher/Candidate
Interviews
Visual Technology
Resources/Materials/Technology/Space
Other
Category
Exemplary 3 Points
(Distinguished)
Superior 2 Points
(Proficient)
Criteria for Rating
The candidate
consistently and
thoroughly
demonstrates
indicators of
performance.
The candidate usually and
extensively demonstrates
indicators of performance.
Rating
(Indicate √)
Justification for Evaluation
8
Satisfactory 1 Point
(Basic but Experience and
Improvement Needed)
The candidate sometimes
and adequately
demonstrates indicators
of performance.
Unsatisfactory 0 Points
(Not trying/Poor Attitude/
Lack of Essential Skills)
The candidate rarely or
never and inappropriately or
superficially demonstrates
indicators of performance.
Student/Candidate’s Last Name
First
Middle
Social Security Number
– Instructional Delivery - Student teacher/candidate, through knowledge of content, pedagogy and
skill in delivering instruction, engages students in learning by using a variety of instructional strategies.
Alignment: 354.33. (1)(i)(D),(F),(G)
Category III
Student Teacher/candidate’s performance appropriately demonstrates:
Use of knowledge of content and pedagogical theory through his/her instructional delivery
Instructional goals reflecting Pennsylvania K-12 standards
Communication of procedures and clear explanations of content
Use of instructional goals that show a recognizable sequence, clear student expectations, and adaptations for individual student
needs
Use of questioning and discussion strategies that encourage many students to participate
Engagement of students in learning and adequate pacing of instruction
Feedback to students on their learning
Use of informal and formal assessments to meet learning goals and to monitor student learning
Flexibility and responsiveness in meeting the learning needs of students
Integration of disciplines within the educational curriculum
Sources of Evidence (Check all that apply)
Classroom Observations
Informal Observations/Visits
Assessment Materials
Student Teacher/Candidate
Interviews
Student Assignment Sheets
Student Work
Instructional Resources/Materials/Technology
Other
Category
Exemplary 3 Points
(Distinguished)
Superior 2 Points
(Proficient)
Criteria for Rating
The candidate
consistently and
thoroughly
demonstrates
indicators of
performance.
The candidate usually and
extensively demonstrates
indicators of performance.
Rating
(Indicate √)
Justification for Evaluation
9
Satisfactory 1 Point
(Basic but Experience and
Improvement Needed)
The candidate sometimes
and adequately
demonstrates indicators
of performance.
Unsatisfactory 0 Points
(Not trying/Poor Attitude/
Lack of Essential Skills)
The candidate rarely or
never and inappropriately or
superficially demonstrates
indicators of performance.
Student/Candidate’s Last Name
First
Middle
Social Security Number
Category IV – Professionalism - Student teacher/candidate demonstrates qualities that characterize a
professional person in aspects that occur in and beyond the classroom/building.
Alignment: 354.33. (1)(i)(I),(J)
Student Teacher/Candidate’s performance appropriately demonstrates:
Knowledge of school and district procedures and regulations related to attendance, punctuality and the like
Knowledge of school or district requirements for maintaining accurate records and communicating with families
Knowledge of school and/or district events
Knowledge of district or college’s professional growth and development opportunities
Integrity and ethical behavior, professional conduct as stated in Pennsylvania Code of Professional Practice and Conduct for
Educators; and local, state, and federal, laws and regulations
Effective communication, both oral and written with students, colleagues, paraprofessionals, related service personnel, and
administrators
Ability to cultivate professional relationships with school colleagues
Knowledge of Commonwealth requirements for continuing professional development and licensure
Sources of Evidence (Check all that apply)
Classroom Observations
Informal Observations/Visits
Assessment Materials
Student Teacher Interviews
Written Documentation
Student Assignment Sheets
Student Work
Instructional Resources/Materials/Technology
Other
Category
Exemplary 3 Points
(Distinguished)
Superior 2 Points
(Proficient)
Criteria for Rating
The candidate
consistently and
thoroughly
demonstrates
indicators of
performance.
The candidate usually and
extensively demonstrates
indicators of performance.
Rating
(Indicate √ )
Justification for Evaluation
10
Satisfactory 1 Point
(Basic but Experience and
Improvement Needed)
The candidate sometimes
and adequately
demonstrates indicators
of performance.
Unsatisfactory 0 Points
(Not trying/Poor Attitude
Lack of Essential Skills)
The candidate rarely or
never and inappropriately or
superficially demonstrates
indicators of performance.
Student/Candidate’s Last Name
First
Middle
Social Security Number
Overall Rating
Category
Exemplary
(Distinguished)
Superior
(Proficient)
Total: >11 to12 Points
Total: >7 to < l1 Points
Satisfactory
(Basic but Experience
and Improvement
Needed)
Unsatisfactory
(Not trying/Poor Attitude
Lack of Essential Skills)
Total: 0 to < 4 Points
Criteria for Rating
The candidate
consistently and
thoroughly
demonstrates indicators
of performance.
The candidate usually and
extensively demonstrates
indicators of performance.
Total: > 4 to < 7 Points
The candidate sometimes
and adequately
demonstrates indicators
of performance.
The candidate rarely or
never and inappropriately or
superficially demonstrates
indicators of performance.
Rating
(Indicate √ )
Note: This assessment instrument must be used a minimum of two times. PDE requires a satisfactory rating (1) in
each of the 4 categories, resulting in a minimum total of at least (4) points, must be achieved on the final
summative rating to favorably complete this assessment. However, EUP standards require a satisfactory score
or better on both the midterm and final evaluation. If your student intern will have a ZERO (0) in any area for
either evaluation, please contact Dr. Susan Hegel at shegel@edinboro.edu or at 814-732-2192.
Justification for Overall Rating:
Student Teacher/Candidate’s Last Name
Number
First
District/IU
School
School Year:
Term:
Middle
Social Security
Interview/Conference Date
Required Signatures:
Supervisor/Evaluator:
Date:
Student/Teacher
Candidate:
Date:
University Supervisor
Date:
11
PDE Competencies for the Pre-field and Internship Experiences
Candidate:____________________
Please check and initial boxes indicating skill level and sign the last page
A. Planning and Preparation
The candidate demonstrates
1. Knowledge of remediation methods and therapeutic
design based on sound educational pedagogy and
psychology principles.
2. Knowledge of Pa. Pre-K-12 Academic Standards and
the ability to use them to guide instructional planning.
3. Knowledge of the age and/or related characteristics of
their students and the ability to use this knowledge to
plan specifically designed instruction.
4. The ability to use formative and summative
assessments to adapt learning goals to support
individual student needs.
5. The ability to plan instruction using appropriate
resources, materials, technology and activities to
engage students in meaningful learning based on their
instructional goals.
Pre-Field
Beginner
Basic Skills
(emerging skills)
(adequate)
Extensive support
Tasks completed
and guidance
with support;
needed to complete emerging
tasks. Focus on
awareness of
task, not client
clients’ needs.
Internship
Proficient
Advanced
Skills
Skills
Tasks completed
Tasks completed
independently with
independently
recognition and
with recognition
adjustments for
of clients’ needs.
clients’ needs
B. Classroom Environment
The candidate:
Pre-Field
Beginner
Basic Skills
(emerging skills)
(adequate)
Extensive support
Tasks completed
and guidance
with support;
needed to complete emerging
tasks. Focus on
awareness of
task, not client
clients’ needs.
1. Maintains a culture which values the development of
meaningful, caring, and respectful relationships
2. Recognizes and supports the role of the prepared
classroom/therapy environment as a necessary
element to support optimal learning opportunities.
3. Uses classroom and other resources to support equity
and maximize learning opportunities, which are age-,
gender-, individually-, culturally- and abilityappropriate.
4. Assesses classroom and other resources in order to
make adaptations and accommodations required to
differentiate instruction for all learners.
5. Identifies opportunities for productive family and
community contact.
6. Demonstrates knowledge of and acts to support
systems for student transitions, as well as procedures
and routines for instructional and non-instructional
responsibilities.
13
Internship
Proficient
Advanced
Skills
Skills
Tasks completed
Tasks completed
independently with
independently
recognition and
with recognition
adjustments for
of clients’ needs.
clients’ needs
C. Instructional Delivery
The candidate
Pre-Field
Beginner
Basic Skills
(emerging skills)
(adequate)
Extensive support
Tasks completed
and guidance
with support;
needed to complete emerging
tasks. Focus on
awareness of
task, not client
clients’ needs.
1. Uses effective verbal and non-verbal communication
techniques.
2. Uses effective questioning and discussion techniques.
3. Uses a variety of age-, gender-, individually-, culturally-,
ability- and skill-appropriate instructional strategies,
which reflect evidence of student engagement, new
learning and assessment.
4. Uses technology as an effective teaching and learning tool.
5. Provides appropriate progress feedback to students in a
timely manner.
6. Uses active student engagement during instructional
delivery.
7. Uses formal and/or informal assessment to measure
student responsiveness to instruction.
8. Constructs thoughtful and accurate assessment of a
lesson’s effectiveness and the extent to which learning
goals were achieved and can offer alternative actions if
necessary.
9. Clearly communicates instructional goals, procedures and
content.
14
Internship
Proficient
Advanced
Skills
Skills
Tasks completed
Tasks completed
independently with
independently
recognition and
with recognition
adjustments for
of clients’ needs.
clients’ needs
D. Professional Conduct
The candidate:
Pre-Field
Beginner
Basic Skills
(emerging skills)
(adequate)
Extensive support
Tasks completed
and guidance
with support;
needed to complete emerging
tasks. Focus on
awareness of
task, not client
clients’ needs.
1. Initiates communication with the cooperating teacher
regarding instructional and non-instructional record
keeping, procedures and routines, and timelines;
including, but not limited to, grading, attendance,
lesson plans, data keeping, parent communication,
and inter-school needs.
2. Demonstrates knowledge of and participates in
district, college, regional, state and/or national
professional development growth and development
opportunities.
3. Exhibits integrity, ethical behavior and professional
conduct as stated in the “PA Code of Professional
Practice & Conduct for Educators,” as well as local,
state and federal laws and regulations.
4. Applies safety precautions and procedures
5. Complies with school policies and procedures
regarding professional dress, attendance, punctuality
and the use of technology.
6. Develops and maintain professional relationships
with school colleagues.
15
Internship
Proficient
Advanced
Skills
Skills
Tasks completed
Tasks completed
independently with
independently
recognition and
with recognition
adjustments for
of clients’ needs.
clients’ needs
E. Assessment and Evaluation
The candidate:
Pre-Field
Beginner
Basic Skills
(emerging skills)
(adequate)
Extensive support
Tasks completed
and guidance
with support;
needed to complete emerging
tasks. Focus on
awareness of
task, not client
clients’ needs.
1. Identifies various types of assessment tools used in
instruction including formative, summative,
benchmark, behavioral, diagnostic, cognitive,
affective and psychomotor.
2. Makes norm-referenced and criterion-referenced
interpretations of assessment results.
3. Applies interpretations to inform planning and
instruction for groups and individual students.
4. Applies interpretations of status (PSSA) and growth
(PVASS) assessment models to inform planning and
instruction for groups and individual students.
5. Constructs assessments to match cognitive, affective,
behavioral and/or psychomotor curricular goals.
6. Constructs assessments to match curricular goals
along a continuum of complexity (e.g. Bloom’s
taxonomy).
7. Assesses their own professional growth through
focused self-reflection.
16
Internship
Proficient
Advanced
Skills
Skills
Tasks completed
Tasks completed
independently with
independently
recognition and
with recognition
adjustments for
of clients’ needs.
clients’ needs
Pre-Field
Beginner
Basic Skills
(emerging skills)
(adequate)
Extensive support
Tasks completed
and guidance
with support;
needed to complete emerging
tasks. Focus on
awareness of
task, not client
clients’ needs.
F. Knowledge of Diverse Learners
The candidate:
1. Reports on the unique characteristics and learning
needs of diverse learners (age, gender, culture or
ability) in the classroom
2. Recognizes and supports elements of a positive
learning environment that values and models respect
for all students.
3. Differentiates instruction to meet the needs of diverse
learners that promotes successful educational
performance.
4. Recognizes policies and procedures designed to
ensure that all students, particularly those
traditionally underserved, are valued in the school.
5. Reports on effective practices and opportunities
designed to communicate with and engage families,
caregivers, and the broader community.
ASHA CCC-SLP Supervisors:
Name
Date
ASHA Number
17
Comments
Internship
Proficient
Advanced
Skills
Skills
Tasks completed
Tasks completed
independently with
independently
recognition and
with recognition
adjustments for
of clients’ needs.
clients’ needs
Additional Signature Page
ASHA CCC-SLP Supervisors: (print more pages as needed)
Name
Date
ASHA Number
18
Comments
Invoice for In-State (PA only) Supervisors
Edinboro University
School-Based Internship Supervision
Due by June 10th!
Return this completed form with:
1. Final PDE 430 Evaluation
2. Final PDE 430A supporting documentation
3. Completed Competency Checklist based on PDE Internship (Stage 4) Expectations
Student's Name
Date(s) of Student Teaching Experience
From:
To:
Pennsylvania School District/Site
Address
City, State, Zip
Supervisor’s Name: ______________________________
Supervisor’s Social Security Number: ____________________________
I was:
_____ the sole supervisor for this student intern ($300.00 stipend)
_____ a half-time supervisor for this student intern ($150.00 stipend)
_____ a part-time supervisor for this student intern with a negotiated stipend of $__________.
Please send my check to:
Address
City, State, Zip
Telephone Number
Signature, Student Teaching Supervisor
Return this form by hard copy, fax, or e-mail with signatures to:
Susan Hegel, Ph.D., CCC-SLP
Speech, Language and Hearing Department
215 Scotland Road, Room 241
Edinboro University
Edinboro, PA 16444
Processing paperwork for checks can sometimes take weeks.
Please complete and return this form any time after the midterm evaluation!
Please contact me if you have any questions. Thank you again for your willingness to be part of
our program and mentor our students. Though they may not recognize your gifts of time and
knowledge, we certainly do!
Susan L. Hegel, Ph.D., CCC-SLP
Coordinator of School-Based Internships
shegel@edinboro.edu
814-732-2192 work
814-860-1178 cell
814-732-2612 FAX
20