Verification of Observation Hours
Applicants to the Teacher Preparation Program at Central Washington University must complete
40 hours of observation prior to enrolling in EFC 210. Hours completed in the Ellensburg School
District may not be used to satisfy this requirement. Each teacher or supervisor under whom the
prospective teacher candidate observes should complete a separate form. Bring all completed forms to
the first meeting of your EFC 210 class.
Date
_____________________
Grade Level or Age Level
Hours
Observed
Date
______________________________
Title of Teacher or Supervisor
Hours
Observed
_________________
Total Hours
____________________________________
School or Organization
_____________________________________
Phone
_____________________________________
Address
_____________________________________
City, State, Zip
I certify that the above information is accurate.
_____________________________
Student Name (Print)
_____________________________
Student Name (Sign)
____________
Date
I certify that the above information is accurate.
_____________________________
Teacher/Supervisor Name (Print)
(revised 5/15/12)
_____________________________
Teacher/Supervisor Name (Sign)
____________
Date