Complete this sheet in its entirety. You are required to submit this hardcopy to your instructor.
Spadoni College of Education
Field Experience/Student Teaching Diversity Form
Your Name
Female
CCU ID
Male
Program Area
Course Name/Number for Field Experience
Name of Instructor
Field Experience (place a check for the applicable field experience)
Freshman Immersion Day
Field Experience II (Jr. I)
Field Experience III (Jr. II)
Field Experience IV (Sr. I)
MAT Fall Methods
Student Teaching/Internship
Semester/Year of Field Experience
Name of School for Field Experience
Cooperating Teacher’s Name
Female
Male
Cooperating Teacher’s E-mail Address
Cooperating Teacher’s Signature
Grade Level Placement
Subject(s)
Field Experience Beginning Date
Field Experience Ending Date
IF YOUR PLACEMENT SERVES MORE THAN ONE CLASS AT THE SAME SCHOOL,
CHOOSE ONE CLASSROOM AND COMPLETE THE FOLLOWING FOR THAT CLASSROOM.
Type of Classroom Experience (check all that apply)
General Education
Resource Room
Collaboration (General & Special)
Other
Experiences with Special Needs (check all that apply AND enter the NUMBER of children in the classroom
for each exceptionality checked in the designated space)
English Language Learners
Gifted/Talented
Special Education
Speech
Occupational Therapy
Other, specify
Classroom Student Ethnicity (check all that apply)
Black or African-American
White
Native Hawaiian or Pacific Islander
Hispanic or Latino
Some other race
American Indian/Alaskan Native
Asian
Two or more races
Cooperating Teacher Ethnicity (check all that apply)
Black or African-American
White
Native Hawaiian or Pacific Islander
Hispanic or Latino
Some other race
American Indian/Alaskan Native
Two or more races
School Diversity/Socioeconomic Status
# Free/Reduced Student Lunch Percentage:
Greater than or equal to 55%
Less than 55%
* Racial Minority:
Greater than or equal to 40%
Less than 40%
Final Version as of 8/24/2015 J. Dix (removed electronic submission requirement.)
Asian