Pre-Practicum Field Experience Documentation Spring 2009

The Graduate College of Education seeks to prepare excellent teachers, administrators, and counselors. The purpose of this data collection is to confirm your demographic information and UMS identification numbers. Your identification number is especially important as is allows us to confirm your student information across all of your student records. We greatly appreciate your taking the time to provide this information.

1. Your First Name:

Your First Name:

2. Your Last Name:

Your Last Name:

3. Your UMS number (student I.D.):

Your UMS number (student I.D.):

4. Licensure sought:

Licensure sought: Initial

Professional

5. Subject:

Subject:

6. Grade Level:

Grade Level: Elementary	Middle	Secondary	PreK-8	5-12
Other (please specify)

Course with which pre-practicum work was associated:

7. Name of Instructor:

Name of Instructor:

8. Course Name:

Course Name:

9. Course Number:

Course Number:

10. Semester and Year:

Semester and Year: Summer 2008

Spring 2009

Summer 2009

Fall 2009

School or community setting:

11. Name of school or organization:

Name of school or organization:

12. City/Town:

City/Town:

13. Subject taught:

Subject taught:

14. Number of students in class:

Number of students in class:

15. Type of setting

Type of setting Urban

Suburban

Rural

16. Check one

Check one General Education

Special Education

Inclusion

17. Type of pre-practicum work
(check all that apply)

Type of pre-practicum work (check all that apply) Observing Classroom

Developing Behavioral Management Plans

Evaluating Student Work

Instructing Whole Group

Tutoring

Reflecting on One’s Practice

Interviewing Practitioner

Creating Assignments

Instructing Small Group

Interviewing Parent/Caregiver

Planning Lessons/Units

Assessing Individual Students

Other

18. Total number of pre-practicum hours related to the assignment(s):

Total number of pre-practicum hours related to the assignment(s):

Demographics of the Setting: You must use the information from the School Profiles-Enrollment Indicators webpage of the Massachusetts Department of Education to fill out this section. (http://profiles.doe.mass.edu)

19. What is the School Code? (i.e. Boston Latin is 00350560)

What is the School Code? (i.e. Boston Latin is 00350560)

20. Percentage of students who are in Special Education

Percentage of students who are in Special Education

21. Percentage of students whose first language is not English.

Percentage of students whose first language is not English.

22. Percentage of students who are LEP

Percentage of students who are LEP

23. Percentage of students who are low-income

Percentage of students who are low-income

24. Percentage of students who are White

Percentage of students who are White

25. Percentage of students who are African American

Percentage of students who are African American

26. Percentage of students who are Asian

Percentage of students who are Asian

27. Percentage of students who are Hispanic

Percentage of students who are Hispanic

28. Percentage of students who are Native American

Percentage of students who are Native American

29. Percentage of students who are Native Hawaiian/Pacific Islander

Percentage of students who are Native Hawaiian/Pacific Islander

30. Percentage of students who are Multi-Race/Non-Hispanic

Percentage of students who are Multi-Race/Non-Hispanic

31. Add the percentages of non-white students to the percentage of low-income students

Add the percentages of non-white students to the percentage of low-income students

Practitioner/Person who supervised pre-practicum work

32. Name of Practitioner:

Name of Practitioner:

33. His or her work Phone Number:

His or her work Phone Number:

34. License level of practitioner:

License level of practitioner: Initial