Diversity 4.d.2 Form

For program improvement purposes, the School of Education is collecting demographic information about the clinical internship placement.

Clinical Educator Demographics

Data on the Clinical Educator/Cooperating Teacher
Name:
Today's Date: 7/23/2024 9:01:41 AM
School:
Grade/Subject:
Email:
Gender:
Race/Ethnicity (Check appropriate boxes):





Years of Teaching Experience:
Certification Area(s):

Classroom Demographics (as reported by the school/district)
Enrollment by Gender:
% Male:
% Female:
Enrollment by Race/Ethnicity:
% American Indian/Alaska Native:
% Black or African American:
% Asian:
% Hispanic:
% Pacific Islander:
% White:
% Other:
% Unknown:
Classroom Demographics, continued:
% Title I Students:
% Students with Identified Exceptionalities:
% English Language Learners (ELL):
% Advanced Level Students (in at least one content area):
% Free/Reduced-price lunch eligible:
Intern Information
Current Status of Intern (must select):
Intern Name:
Grade/Subject:
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click the 'Submit' button ONCE in a session. If you unsure your form was submitted OR you got a 'critical error' notice in a pink box after form submission, please contact Kellie Hatch to verify if the form was submitted sucessfully.