BHSU - Field Experience: Diversity 4d2 Form

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: 4/17/2024 8:06:13 PM

School:

Grade/Subject:

Email:

Gender: Male
Female

Race/Ethnicity (Check appropriate boxes):    American Indian/Alaska Native
   Black or African American
   Asian
   Hispanic
   Pacific Islander
   White
   Other

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): Undergraduate Student Teaching Internship
Graduate Student Teaching Internship

Intern Name:

Grade/Subject:

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