Diversity 4.d.1 Form
Current Status of Intern (must select):
Intern Name:
Major(s):
Today's Date: 12/9/2022 7:52:31 AM

Field Experiences and Clinical Practices
EDFN 295 or 328 or 595 Pre-Admission Practicum
Semester & Year:
School(s) or Site(s):
Grade Level(s):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (1):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (2):
Which gender(s) did this experience involve?
Did this experience include low SES students?
Did your experience include English Language Learners (ELL) students?
Did your experience include exceptional students?
State whether these students were in Resource Room or inclusive settings.
Did your experience include advanced learners, defined as students working above grade level in at least one content area?
ELED or SEED or ECE 495/695 Pre-Student Teaching Practicum
Semester & Year:
School(s) or Site(s):
Grade Level(s):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (1):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (2):
Which gender(s) did this experience involve?
Did this experience include low SES students?
Did your experience include English Language Learners (ELL) students?
Did your experience include exceptional students?
State whether these students were in Resource Room or inclusive settings.
Did your experience include advanced learners, defined as students working above grade level in at least one content area?
Student Teaching Placement 1
Semester & Year:
School(s) or Site(s):
Grade Level(s):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (1):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (2):
Which gender(s) did this experience involve?
Did this experience include low SES students?
Did your experience include English Language Learners (ELL) students?
Did your experience include exceptional students?
State whether these students were in Resource Room or inclusive settings.
Did your experience include advanced learners, defined as students working above grade level in at least one content area?
Student teaching placement 2 (if applicable)
Semester & Year:
School(s) or Site(s):
Grade Level(s):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (1):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (2):
Which gender(s) did this experience involve?
Did this experience include low SES students?
Did your experience include English Language Learners (ELL) students?
Did your experience include exceptional students?
State whether these students were in Resource Room or inclusive settings.
Did your experience include advanced learners, defined as students working above grade level in at least one content area?
Student teaching placement 3 (if applicable)
Semester & Year:
School(s) or Site(s):
Grade Level(s):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (1):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (2):
Which gender(s) did this experience involve?
Did this experience include low SES students?
Did your experience include English Language Learners (ELL) students?
Did your experience include exceptional students?
State whether these students were in Resource Room or inclusive settings.
Did your experience include advanced learners, defined as students working above grade level in at least one content area?
Other Experiences such as: Teammates, tutoring, other courses, field trips, job experiences, etc.
Semester & Year:
School(s) or Site(s):
Grade Level(s):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (1):
Select a Race or Ethnic Group of P-12 students (other than your own) with whom you have had experience (2):
Which gender(s) did this experience involve?
Did this experience include low SES students?
Did your experience include English Language Learners (ELL) students?
Did your experience include exceptional students?
State whether these students were in Resource Room or inclusive settings.
Did your experience include advanced learners, defined as students working above grade level in at least one content area?
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