NICHOLLS STATE UNIVERSITY
Middle/Secondary Science Evaluation
Student Teacher
Supervising Teacher(s)
University Coordinator
School
Grade/Subject
Evaluation Dates:
First
Second
INSTRUCTIONS FOR USING THIS EVALUATION: Please circle the appropriate description for each domain component for midsemester and at the end of the semester.
The rating used in this instrument is based on a three point scale. It will provide opportunities for further in-depth studies of student
teacher performance. A major reason is that the criteria used herein now directly conforms to the LOUISIANA ASSESSMENT FOR
FIRST YEAR TEACHERS.
Items marked “Unacceptable” should be qualified under the remarks section. Strengths and areas for improvement should also
be identified under the remarks section. PLEASE DO NOT LEAVE THE REMARKS SECTION BLANK. Please attach additional
sheets if needed or use the back of the form.
SPACES ARE PROVIDED FOR SIGNATURES BY THE STUDENT TEACHER, SUPERVISING TEACHER, SUPERVISING
PRINCIPAL, UNIVERSITY COORDINATOR AND COORDINATOR OF STUDENT TEACHING. Signatures must be provided at
mid-semester and at the end of the semester.
“Responsible Leaders Engaging in Professional Practice”
RESPONSIBLE LEADERS:
Take responsibility for their own professional development;
Engage in reflective inquiry and use data to adjust instruction;
Engage in leadership in both the school and the community;
Inquire into and serve the profession;
Inquire into and contribute to current research and scholarship;
Engage in ethical behaviors.
RESPONSIBLE LEADERS:
Teach from the local ecology
(culture, community, & environment);
Demonstrate responsibility for inquiring into the local ecology;
Use local knowledge to transform the learning of all students;
Demonstrate responsibility for serving the needs of
students and the community.
RESPONSIBLE LEADERS:
Transform the lives of all students by creating positive
learning environments;
Use the curriculum to advocate for social change;
Use technology to improve the lives of all students;
Advocate for students in both the school and the community;
Teach for the success of all students.
RESPONSIBLE LEADERS:
Demonstrate an openness to change;
Inquire into the relationship between cultural differences and
learning;
Inquire into the learning needs of students;
Inquire into innovative teaching practices that meet the needs of all
students;
Collaborate with all parties who have an interest in
student success;
Teach students how to use technology to improve their learning.
1
MID-SEMESTER AND FINAL EVALUATION - NSTA
The Student Teacher Final Evaluation Form follows the Louisiana Components of Effective Teaching (LCET) document, and includes
the same components identified by the State Department of Education for Level 1 certification during the first year teaching
evaluation. The components of LCET include planning, management, instruction, professionalism, and school improvement. The
evaluation is completed for each candidate by the university coordinator at mid-term and at the end of the semester. Data collected at
mid-term is used only for candidate feedback.
Directions: Circle the description which best evaluates the extent to which competency is attained.
Domain 1 - Planning (NSTA)- The teacher candidate plans accurate and developmentally appropriate lessons in accordance
with the Nicholls State University Conceptual Framework
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The candidate consistently
The candidate specifies
The candidate infrequently
1. The candidate specifies learner
specifies learner outcomes in learner outcomes in clear, specifies learner outcomes
outcomes in clear, concise objectives
clear, concise objectives
concise objectives
in clear, concise objectives
(1.000, 16%)
The candidate consistently
The candidate includes
The candidate infrequently
2. The candidate includes activities
includes activities that
activities that develop and includes activities that
that develop and assess the objectives
develop and assess the
assess the objectives
develop and assess the
(1.000, 16%)
objectives
objectives
The
candidate
consistently
The
candidate
identifies
and
The candidate infrequently
3. The candidate identifies and plans
identifies and plans for
plans for individual
identifies and plans for
for individual differences (1.000,
individual differences
differences
individual differences
16%)
The candidate consistently
The candidate identifies
The candidate infrequently
4. The candidate identifies materials
identifies materials that are
materials that are developed identifies materials that are
that are developed from the local
developed from the local
from the local ecology,
developed from the local
ecology, other than standard
ecology, other than standard other than standard
ecology, other than standard
classroom material, as needed for the
classroom material, as needed classroom material, as
classroom material, as
lesson (1.000, 16%)
for the lesson
needed for the lesson
needed for the lesson
The candidate consistently
The candidate plans for
The candidate infrequently
5. The candidate plans for method (s)
plans for method (s) of
method (s) of evaluation to plans for method (s) of
of evaluation to measure learner
evaluation to measure learner measure learner outcomes evaluation to measure
outcomes (1.000, 16%)
outcomes
learner outcomes
The candidate consistently
The candidate assists in
The candidate infrequently
6. The candidate assists in IEP, ITP
assists in IEP, ITP and/or
IEP, ITP and/or IFSP
assists in IEP, ITP and/or
and/or IFSP development (for special
IFSP development (for special development (for special
IFSP development (for
education teachers only) (1.000,
education teachers only)
education teachers only)
special education teachers
16%)
only)
Remarks:
Mid-Semester:
Final:
Domain II - Management -- (NSTA) Component A: The teacher candidate maintains an environment conducive to learning.
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The candidate consistently
The candidate organizes
The candidate infrequently
1. The candidate organizes space,
organizes space, materials,
space, materials, and/or
organizes space, materials,
materials, and/or equipment to
2
facilitate learning (1.000, 50%)
NSTA-2012.3d
2. The candidate promotes a positive
learning climate (1.000, 50%)
Target (3 pts)
and/or equipment to facilitate
learning
The candidate consistently
promotes a positive learning
climate
Acceptable (2 pts)
equipment to facilitate
learning
The candidate promotes a
positive learning climate
Unacceptable (1 pt)
and/or equipment to
facilitate learning
The candidate infrequently
promotes a positive learning
climate
Remarks:
Mid-Semester:
Final:
Domain II - Management -- (NSTA) Component B: The teacher candidate maximizes the amount of time available for
instruction
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The candidate consistently
The candidate manages
The candidate infrequently
1. The candidate manages routines
manages routines and
routines and transitions in a manages routines and
and transitions in a timely manner
transitions in a timely manner timely manner
transitions in a timely
(1.000, 50%)
manner
The candidate consistently
The candidate manages
The candidate infrequently
2. The candidate manages and/or
manages and/or adjusts
and/or adjusts allotted time manages and/or adjusts
adjusts allotted time for activities
allotted time for activities
for activities planned
allotted time for activities
planned (1.000, 50%)
planned
planned
Remarks:
Mid-Semester:
Final:
Domain II - Management -- (NSTA) Component C: The teacher candidate manages learner behavior to provide productive
learning opportunities
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The candidate consistently
The candidate establishes The candidate infrequently
1. The candidate establishes
establishes expectations for
expectations for learner
establishes expectations for
expectations for learner behavior
learner behavior
behavior
learner behavior
(1.000, 50%) NSTA-2012.3d
The candidate consistently
The candidate uses
The candidate infrequently
2. The candidate uses monitoring
uses monitoring techniques to monitoring techniques to
uses monitoring techniques
techniques to facilitate learning
facilitate learning
facilitate learning
to facilitate learning
(1.000, 50%) NSTA-2012.3c
Remarks:
Mid-Semester:
3
Final:
Domain III - Instruction -- (NSTA) Component A: The teacher candidate delivers instruction effectively
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The candidate consistently
The candidate uses
The candidate infrequently
1. The candidate uses technique(s)
uses technique(s) (inquiry)
technique(s) (inquiry)
uses technique(s)
(inquiry) which develop(s) lesson
which develop(s) lesson
which develop(s) lesson
(inquiry)which develop(s)
objective(s) (1.000, 25%)
objective(s)
objective(s)
lesson objective(s)
The candidate consistently
The candidate sequences
The candidate infrequently
2. The candidate sequences lessons
sequences lessons to promote lessons to promote learning sequences lessons to
to promote learning (1.000, 25%)
learning
promote learning
The candidate uses a wide
The candidate uses
The candidate does not use a
3. The candidate uses community
variety of community
community resources to
sufficient amount of
resources to promote the learning of
resources to promote the
promote the learning of
community resources to
science (1.000, 25%) NSTA-2012.6a
learning of science
science
promote the learning of
science
The candidate consistently
The candidate adjusts
The candidate infrequently
4. The candidate adjusts lesson
adjusts lesson when
lesson when appropriate
adjusts lesson when
when appropriate using reflective
appropriate using reflective
using reflective practice
appropriate using reflective
practice (1.000, 25%) NSTA-2012.3c
practice
practice
The candidate consistently
The candidate integrates
The candidate integrates
5. The candidate integrates scienceintegrates science-specific
science-specific technology technology that is not
specific technology into instruction
technology into instruction
into instruction
science-specific or
appropriately NSTA-2012.2b
appropriately
appropriately
integrates science-specific
technology into instruction
inappropriately
Remarks:
Mid-Semester:
Final:
Domain III - Instruction -- (NSTA) Component B: The teacher candidate presents appropriate content
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The candidate consistently
The candidate presents
The candidate presents
1. The candidate presents content at
presents content at a
content at a
content at a developmentally
a developmentally appropriate level
developmentally appropriate developmentally
appropriate level but does
using a variety of strategies (1.000,
level using a variety of
appropriate level using a
not use a variety of
33%) NSTA-2012.3a
appropriate strategies
variety of strategies
strategies
The candidate consistently
The candidate presents
The candidate presents
2. The candidate presents accurate
presents accurate subject
accurate subject matter that inaccurate subject matter
subject matter that demonstrates
matter that demonstrates the demonstrates the candidates' that does not fully
the candidates' knowledge and
candidates' high level of
knowledge and
demonstrate the candidates'
understanding of how to select
knowledge and understanding understanding of how to
knowledge and
appropriate teaching and learning
of how to select appropriate select appropriate teaching understanding of how to
activities (1.000, 33%) NSTA-
4
2012.3a
3. The candidate addresses
misconception, relates to real life
examples, unexpected situations, or
current events to the content (1.000,
33%)
Target (3 pts)
teaching and learning
activities
The candidate
comprehensively and
consistently addresses
misconception, relates to real
life examples, unexpected
situations, or current events to
the content
Acceptable (2 pts)
and learning activities
Unacceptable (1 pt)
select appropriate teaching
and learning activities
The candidate addresses
The candidate addresses
misconception, relates to
some but not all of the
real life examples,
following: misconceptions,
unexpected situations, or
relationships to real life
current events to the content examples, unexpected
situations, or current events
to the content
Remarks:
Mid-Semester:
Final:
Domain III - Instruction -- (NSTA) Component C: The teacher candidate provides opportunities for student engagement in
the learning process
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The
candidate
consistently
The
candidate
The
candidate
1. The candidate accommodates
accommodates individual
accommodates individual accommodates some but not
individual differences for the
differences for the equitable differences for the equitable all of the students'
equitable achievement of science
achievement of science
achievement of science
individual differences
literacy for all students (1.000, 25%)
literacy for all students
literacy for all students
NSTA-2012.3b
The candidate consistently
The candidate demonstrates The candidate infrequently
2. The candidate demonstrates the
demonstrates the ability to
the ability to communicate demonstrates the ability to
ability to communicate effectively
communicate effectively with effectively with students
communicate effectively
with students (1.000, 25%)
students
with students
The candidate consistently
The candidate stimulates
The candidate infrequently
3. The candidate stimulates higher
stimulates higher order
higher order thinking at the stimulates higher order
order thinking at the appropriate
thinking at the appropriate
appropriate developmental thinking at the appropriate
developmental levels to allow access
developmental levels to allow levels to allow access so
developmental levels to
so that all student can learn (1.000,
access so that all student can that all student can learn
allow access so that all
25%) NSTA-2012.3a
learn
student can learn
The candidate consistently
The candidate uses
The candidate uses
4. The candidate uses strategies that
uses strategies that are
strategies that are inclusive strategies that are inclusive
are inclusive and motivating for all
inclusive and motivating for and motivating for all
and motivating for most but
students (1.000, 25%) NSTAall students
students
not all students
2012.3a
Remarks:
Mid-Semester:
Final:
5
Domain III - Instruction -- (NSTA) Component D: The teacher candidate assesses student progress effectively
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The candidate consistently
The candidatemonitors
The candidate monitors
1. The candidate monitors ongoing
monitors ongoing
ongoing performance of
ongoing performance of
performance of students through fair
performance of students
students through fair and
students but does not
and equitable assessments (1.000,
through fair and equitable
equitable assessments
provide evidence of use of
25%) NSTA-2012.3c
assessments
fair and equitable
assessments
The candidate consistently
The candidate uses
The candidate effective
2. The candidate uses appropriate
uses appropriate and effective appropriate and effective
technique(s) to evaluate
and effective technique(s) to
technique(s) to continuously technique(s) to continuously students' preconceptions and
continuously evaluate students'
evaluate students'
evaluate students'
ideas but does so
preconceptions and ideas (1.000,
preconceptions and ideas
preconceptions and ideas
inconsistently
25%) NSTA-2012.3c
The candidate provides timely The candidate provides
The candidate provides
3. The candidate provides timely
feedback to students regarding timely feedback to students feedback to students
feedback to students regarding their
their progress on a consistent regarding their progress
regarding their progress but
progress (1.000, 25%)
basis
does not do so in a timely
manner
The candidate consistently
4. The candidate produces The candidate produces
4. The candidate produces evidence
produces evidence of student evidence of student
minimal evidence of student
of student academic growth under
academic growth under
academic growth under
academic growth
his/her instruction through an
his/her instruction through a his/her instruction through
analysis of student learning to
comprehensive analysis of
an analysis of student
evaluate if learning goals are met
student learning to evaluate if learning to evaluate if
(1.000, 25%) NSTA-2012.3c
learning goals are met
learning goals are met
Remarks:
Mid-Semester:
Final:
Domain IV - Professionalism -- (NSTA) Component A: The teacher candidate plans for professional development.
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The candidate consistently
The candidate applies
The candidate applies some
1. The candidate applies ethical and
applies ethical and legal
ethical and legal concepts ethical and legal concepts
legal concepts that demonstrate
concepts that demonstrate
that demonstrate chemical, that but does not fully
chemical, safety, safety procedures,
chemical, safety, safety
safety, safety procedures,
demonstrate chemical,
and the ethical treatment of living
procedures, and the ethical
and the ethical treatment of safety, safety procedures,
organisms within their licensure area
treatment of living organisms living organisms within
and the ethical treatment of
(1.000, 20%) NSTA-2012.3d
within their licensure area
their licensure area
living organisms within
their licensure area
The candidate consistently
The candidate works
The candidate infrequently
2. The candidate works productively
works productively
productively
works productively
(1.000, 20%)
The candidate consistently
The candidate meets school The candidate infrequently
3. The candidate meets school and
meets school and university and university expectations meets school and university
university expectations (1.000, 20%)
expectations
expectations
The candidate seeks
The candidate seeks
The candidate does not seek
4. The candidate seeks professional
professional development
professional development professional development
development opportunities in their
opportunities in their content opportunities in their
opportunities in their
content field such as talks,
6
symposiums, research opportunities,
or projects within their community
(1.000, 20%) NSTA-2012.6a
5. The candidate works cooperatively
with teachers, administrators,
parents, and other school personnel
(1.000, 20%)
Target (3 pts)
field including more than one
of the following areas: talks,
symposiums, research
opportunities, or projects
within their community
The candidate consistently
works cooperatively with all
of the following: teachers,
administrators, parents, and
other school personnel
Acceptable (2 pts)
content field such as talks,
symposiums, research
opportunities, or projects
within their community
Unacceptable (1 pt)
content field such as talks,
symposiums, research
opportunities, or projects
within their community
The candidate works
cooperatively with teachers,
administrators, parents, and
other school personnel
The candidate works
cooperatively with some but
not all of the following:
teachers, administrators,
parents, and other school
personnel
Remarks:
Mid-Semester:
Final:
Domain V - School Improvement -- (NSTA) Component A: The teacher creates partnership with parents/caregivers and
colleagues.
Target (3 pts)
Acceptable (2 pts)
Unacceptable (1 pt)
The candidate consistently
The candidate provides
The candidate infrequently
1. The candidate provides clear and
provides clear and timely
clear and timely
provides clear and timely
timely information to
information to
information to
information to
parents/caregivers and colleagues
parents/caregivers and
parents/caregivers and
parents/caregivers and
regarding classroom expectations,
colleagues regarding
colleagues regarding
colleagues regarding
student progress, and ways they can
classroom expectations,
classroom expectations,
classroom expectations,
assist learning (1.000, 33%)
student progress, and ways
student progress, and ways student progress, and ways
they can assist learning
they can assist learning
they can assist learning
The candidate consistently
The candidate encourages The candidate infrequently
2. The candidate encourages
encourages parents/caregivers parents/caregivers to
encourages
parents/caregivers to become active
to become active partners in become active partners in parents/caregivers to
partners in their children's
their children's education and their children's education
become active partners in
education and to become involved in
to become involved in school and to become involved in their children's education
school and classroom (1.000, 33%)
and classroom
school and classroom
and to become involved in
school and classroom
The candidate seeks
The candidate seeks
The candidate does not seek
3. The candidate seeks community
community involvement in
community involvement in community involvement in
involvement in instructional
instructional programs in
instructional programs such instructional programs such
programs such as conferences,
more than one of the
as conferences, research
as conferences, research
research opportunities, or projects
following areas: conferences, opportunities, or projects
opportunities, or projects
(1.000, 33%) NSTA-2012.6b
research opportunities, or
projects
Remarks:
Mid-Semester:
Final:
7
Domain VI - Teacher Competency - (NSTA) Component A - Safety
Target (3 pts)
The candidate design
1. The candidate designs activities
activities that consistently
that demonstrate the safe and
demonstrate the safe and
proper techniques for the
proper techniques for the
preparation, storage, dispensing,
preparation, storage,
supervision, and disposal of all
dispensing, supervision, and
materials used within their subject
disposal of all materials used
area science instruction (1.000,
within their subject area
14%) NSTA-2012.4a
science instruction
2. The candidate designs and
demonstrates activities that
demonstrate an ability to implement
emegency procedures (1.000, 14%)
NSTA-2012.4b
3. The candidate designs and
demonstrates activities that
demonstrate an ability to maintain
safety equipment, policies and
procedures that comply with
established state and/or national
guidelines (1.000, 14%) NSTA2012.4b
4. The candidate ensures safe
science activities appropriate for the
abilities of all students (1.000, 14%)
NSTA-2012.4b
5. The candidate designs and
demonstrates activities that
demonstrate ethical decisionmaking with respect to the
treatment of all living organisms in
and out of the classroom. (1.000,
14%) NSTA-2012.4c
6. The candidate emphasizes safe,
humane, and ethical treatment of
animals (1.000, 14%) NSTA-2012.4c
7. The candidate complies with the
legal restrictions on the collection,
keeping, and use of living organism
(1.000, 14%) NSTA-2012.4c
The candidate consistently
designs and demonstrates
activities that demonstrate an
ability to implement
emergency procedures
The candidate designs and
demonstrates activities that
consistently demonstrate an
ability to maintain safety
equipment, policies and
procedures that comply with
established state and national
guidelines
The candidate consistently
ensures safe science
activities appropriate for the
abilities of all students
The candidate consistently
designs and demonstrates
activities that demonstrate
ethical decision-making with
respect to the treatment of all
living organisms in and out
of the classroom.
The candidate consistently
emphasizes safe, humane,
and ethical treatment of
animals
The candidate consistently
complies with the all legal
restrictions on the collection,
keeping, and use of living
organism
Acceptable (2 pts)
The candidate designs
activities that demonstrate
the safe and proper
techniques for the
preparation, storage,
dispensing, supervision, and
disposal of all materials
used within their subject
area science instruction
The candidate designs and
demonstrates activities that
demonstrate an ability to
implement emergency
procedures
The candidate designs and
demonstrates activities that
demonstrate an ability to
maintain safety equipment,
policies and procedures that
comply with established
state and/or national
guidelines
The candidate ensures safe
science activities
appropriate for the abilities
of all students
The candidate designs and
demonstrates activities that
demonstrate ethical
decision-making with
respect to the treatment of
all living organisms in and
out of the classroom.
The candidate emphasizes
safe, humane, and ethical
treatment of animals
The candidate complies
with the legal restrictions on
the collection, keeping, and
use of living organism
Unacceptable (1 pt)
The candidate design
activities that demonstrate the
safe and proper techniques
for some but not all of the
following: preparation,
storage, dispensing,
supervision, and disposal of
all materials used within their
subject area science
instruction
The candidate infrequently
designs and demonstrates
activities that demonstrate an
ability to implement
emergency procedures
The candidate designs and
demonstrates activities that
infrequently demonstrate an
ability to maintain safety
equipment, policies and
procedures that comply with
established state and/or
national guidelines
The candidate ensures safe
science activities but that are
not appropriate for the
abilities of all students
The candidate infrequently
designs and demonstrates
activities that demonstrate
ethical decision-making with
respect to the treatment of all
living organisms in and out
of the classroom.
The candidate infrequently
emphasizes safe, humane,
and ethical treatment of
animals
The candidate infrequently
complies with the legal
restrictions on the collection,
keeping, and use of living
organism
Remarks:
Mid-Semester:
Final:
8
Domain VII - Dispositions -- (NSTA)
1. The candidate demonstrates
enthusiasm for teaching and
learning (1.000, 12%)
2. The candidate demonstrates
initiative (1.000, 12%)
3. The candidate conveys confidence
and professionalism when
interacting with students, peers,
and/or professionals in small and
large group situations (1.000, 12%)
4. The candidate meets assignment
due dates (1.000, 12%)
5. The candidate's dress and
grooming are appropriate (1.000,
12%)
6. The candidate is punctual and
attends regularly (1.000, 12%)
7. The candidate demonstrates good
judgment and discretion when
interacting with peers and
professional (1.000, 12%)
8. The candidate interacts positively
with learners, including those from
diverse background (1.000, 12%)
Target (3 pts)
The candidate consistently
demonstrates enthusiasm for
teaching and learning
The candidate consistently
demonstrates initiative
The candidate consistently
conveys confidence and
professionalism when
interacting with students,
peers, and/or professionals in
small and large group
situations
The candidate consistently
meets assignment due dates
The candidate's dress and
grooming are consistently
appropriate
The candidate is consistently
punctual and attends
regularly
The candidate consistently
demonstrates good judgment
and discretion when
interacting with peers and
professionals
The candidate consistently
interacts positively with
learners, including those
from diverse backgrounds
Acceptable (2 pts)
The candidate demonstrates
enthusiasm for teaching and
learning
The candidate demonstrates
initiative
The candidate conveys
confidence and
professionalism when
interacting with students,
peers, and/or professionals
in small and large group
situations
The candidate meets
assignment due dates
The candidate's dress and
grooming are appropriate
Unacceptable (1 pt)
The candidate infrequently
demonstrates enthusiasm for
teaching and learning
The candidate infrequently
demonstrates initiative
The candidate infrequently
conveys confidence and
professionalism when
interacting with students,
peers, and/or professionals in
small and large group
situations
The candidate infrequently
meets assignment due dates
The candidate's dress and
grooming are infrequently
appropriate
The candidate is punctual The candidate is infrequently
and attends regularly
punctual or does not attend
regularly
The candidate demonstrates The candidate infrequently
good judgment and
demonstrates good judgment
discretion when interacting and discretion when
with peers and professional interacting with peers and
professionals
The candidate interacts
The candidate infrequently
positively with learners,
interacts positively with
including those from
learners, including those from
diverse background
diverse backgrounds
Remarks:
Mid-Semester:
Final:
9
MID-SEMESTER FORMATIVE EVALUATION
Supervising Teachers: Please place your signature either in the “Satisfactory” or “Unsatisfactory” blank in addition to the Signature
section.
_____________________________________________
(SATISFACTORY)
_________________________________________
(UNSATISFACTORY)
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(please attach additional sheets if necessary)
SIGNATURES
Student Teacher
Supervising Teacher
University Coordinator
Supervising Principal
Coordinator of Student Teaching
FINAL SUMMATIVE EVALUATION
_____________________________________________
(SATISFACTORY)
_________________________________________
(UNSATISFACTORY)
_____________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
(please attach additional sheets if necessary)
SIGNATURES
Student Teacher
University Coordinator
Supervising Teacher
Supervising Principal
Coordinator of Student Teaching
10