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:
10/22/2025 10:39:30 AM
School:
Grade/Subject:
Email: *
You must enter a VALID email address.
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: *
Please select one
Grade/Subject:
Anti-Spam Verification
Enter the Captcha Code: *
Please enter the Captcha Code.
Important:
Click the 'Submit' button ONCE in a session. If you are 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 successfully.