Diversity of Faculty/Clinical Educators 4.b Form
Current Status:
Intern Name:
Major(s):
Today's Date: 12/9/2022 9:38:59 AM

Identify Diverse Faculty/Clinical Educator

For program development purposes, the School of Education is collecting information about your interactions with diverse populations during your time in the education preparation programs. Self-report your experiences working with diverse professionals in your classes or through other experiences during your programs study.

Ethnicity/Race 1

For the following prompts, respond for an ethnicity/race different than your own.

Name of Faculty/Clinical Educator:
Identify Ethnicity/Race if known:
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):
Ethnicity/Race 2

For the following prompts, respond for an ethnicity/race different than your own.

Name of Faculty/Clinical Educator:
Identify Ethnicity/Race if known:
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):
Gender

How many education professionals have you worked with who identify as the same gender as yourself?"

How many education professionals have you worked with who identify as a different gender from yourself?"

Identify Type of Experiences (Select all that apply):
English Language Learner (ELL) or English as a Second Language (ESL)

How many professionals have you worked with that you would identify as ELL or ESL?"

Identify Type of Experiences (Select all that apply):
Please describe additional interactions with diverse populations that were not represented on this form.
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