LIST OF EXHIBITS FOR STANDARD 3

EXHIBIT 3b.17

                                                         Southeastern Louisiana University                   FORM A:CF

                                          College of Education and Human Development (Revised 7/25/2007)

                                                            Hammond, LA 70402                                               

Please complete the following information. 

Please check your role:     Supervising Teacher of Student Teachers        University Supervisor     

__  Cooperating Teacher 

Name: ____________________________________________________________________________

                                                First                                        Middle                                   Last                       Maiden

School/Site:___________________________________ Parish/District___________________________

                                    (if applicable) 

Current Teaching Assignment: ___________________________________________________________

                                                                                                Grade Level(s)                                      Subject(s)

Gender:   M  F    

 E-mail:_______________________________

Fluent in Multiple Languages:   Yes     No 

Race:

American Indian or Alaskan Native                              Hispanic
Asian or Pacific Islander                                                 Not Reported|
Black, Non-Hispanic                                                        White, Non- Hispanic|
Foreign/Non-Resident Alien 

Please check all that apply:

 State Certification       National Board Certification     Currently Seeking National Board Certification      

Certification Type: If you are not sure, please check the Teach LA site (http://teachlouisiana.net)

Type A                                                                Practitioner Teacher
Type B                                                                 Out of State Provisional Certification
Type C                                                                 Out of Field Authorization to Teach
Level 1 Professional Certification                   Temporary Authority to Teach
Level 2 Professional Certification                   Temporary Employment Permit
Level 3 Professional Certification                   Ancillary Certification 

Certification Areas: Please check all that apply.

Elementary Grades 1-8                                      Vocational Agriculture                   Mild/Moderate
Elementary Grades 1-6                                      Vocational Home Econ.                 Severe/Profound
Lower Elem. Grades 1-4                                    Family & Cons. Science                 Mentally Retarded
Upper Elem. Grades 5-8                                    Physical Education                         Learning Disabled
Kindergarten                                                      Health & Physical Ed.                    Academically Gifted
Nursery School                                                   Driver/Traffic Safety Ed.              School Librarian
Early Interventionist                                         Aerospace Education                    Media Specialist
English                                                                French                                              Guidance Counselor
Math                                                                    Spanish                                           Counselor in Elem./Sec. Schools General Science                                                  Journalism                                         

Biology                                                               Speech                                 Supervisor of Student   Teaching
Reading Specialist   Chemistry                   Bus/Office Ed.                    Principal (K-12)
Physical Science                                                Bus. Ed. Subjects              Elementary School Principal
Social Studies                                                    Coop. Office Ed.                Secondary School Principal
Instrumental Music                           Computer Literacy             Parish/City School Sup. Of Instruction
Art                                                       Health Occupation                            School Superintendent
Other:________________________________________________________________________________

Are you currently teaching/working in your area of certification?     Yes                No 

Highest Degree Earned:   Bachelor’s                Master’s          Master’s +30       Specialist              Doctoral 

University Granting Degree: _____________________________________________ 

Total Years Teaching:_________  

How often do you incorporate the use of technology into your teaching and learning activities?

  daily                   weekly                                monthly 

How often do your students use technology in learning activities?

  daily                   weekly                                monthly 

How often do you develop and teach lessons that incorporate diversity (ethnic, racial, gender, and socioeconomic groups)?          daily  weekly     monthly              annually 

Do you meet the qualifications to serve as a Supervisor of Student Teaching?            Yes     No 

Have you completed assessor training through the Louisiana Teaching Assistance and Assessment Program?            Yes     No 

Have you completed mentor training through the Louisiana Teaching Assistance and Assessment Program?   Yes     No          

 *NOTES:  

Supervising Teacher of Student Teachers: Submit to the assigned university supervisor working with you and your student teacher or intern. 

Field Experience Cooperating Teacher:     1.    Submit to the principal for university faculty to collect;                                                              2.     e-mail to  jvicknair@selu.edu    or                                                                        3.     mail to     Janis Vicknair, Director
                                                                                                      Field Experience
                                                                                                      SLU 10671   Hammond, LA  70402

                                                                            4.    Form A must be submitted to appropriate university          
                                                                                    personnel before ANY field experience candidate can  begin 
                                                                                    observation and/or participation in direct  teaching.