1. Internship Information

Note: If you are unable to obtain classroom level data for any categories, seek out school level percentages and then calculate the number of students in your class that would equal the school level percentage. (E.g., if you have 22 students in your class and 75% of school students are on free/reduced lunch, then 0.75 x 22 =16.5 students in your class on free/reduced lunch).

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* 1. Intern Name (First and Last)

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* 2. Please indicate on which of the following you are reporting information:

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* 3. What year are you reporting this experience?

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* 4. What semester are you reporting this internship experience?

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* 5. Describe the type of classroom setting you teach in (Inclusions, Self-Contained, Resource Setting, etc):

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* 6. Grade of the students for which you are reporting:

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* 7. Number of students in the classroom:

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* 8. Student Gender and Economic Status 

Below, please enter the number of students in each category.

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* 9. Student Race/Ethnicity 

Below, please enter the number of students in each category.

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* 10. Special Needs 

Please indicate whether you worked with the following students. Check all that apply.

Thank You!

Thank you for taking the time to complete this report. Click "Done" below, and your responses will be submitted.
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