NKU Admissions/Field Experience P-12 Educator Information Form

This form is used to log and track local P-12 Educators (formerly cooperating teachers) working with Northern Kentucky University's Department of Teacher Education to oversee students in their Admissions and Field Placements. 

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* 1. First Name

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* 2. Last Name

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* 3. Maiden

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* 4. Home Street Address

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* 5. City

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* 6. State

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* 7. Zip

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* 8. School Name

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* 9. School Email Address

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* 10. School Phone (ex: 000-000-0000)

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* 11. How many NKU Admissions/Field Experience Students are you working with this semester?

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* 12. Name of NKU Admissions/Field Experience Students(s) with whom you are working this semester:

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* 13. Which grade(s) do you currently teach?

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* 14. What subject(s) do you currently teach?

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* 15. Are you an NKU employee?

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* 16. We are accredited by the Council for the Accreditation of Educator Preparation (CAEP) and are required to report the diversity of our teacher educators. Please review the categories of diversity below and check the ones appropriate for you. This information will not be published for individual teachers but instead will be aggregated and reported as part of the entire group of teacher educators that work with us each semester.

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* 17. How do you describe yourself?

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* 18. I have read the practicum information given to me by Northern Kentucky University. I understand my duties and responsibilities as a cooperating teacher and know that I should contact the professor with any questions I might have. (Please type our name as your electronic signature). 

If this is your first time to supervise a Northern Kentucky University admissions or field experience student, we will contact you personally for more information. 
If you have any questions regarding this form, please contact Emily Burford at burforde1@nku.edu. 

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