A

REGENT UNIVERSITY
SCHOOL OF EDUCATION
Teacher Candidate Personal Data Form

Name_________________________________________________Date_________________________

Address ___________________________________________________________________________

Home Phone No. ________________________ Emergency Phone No._________________________

Email address ___________________________________(Cell)______________________________

Regent University Program of Study_____________________________________________________

**********************************************************************************
Undergraduate College Major _______________________________ Minor _____________________

College/University___________________________________________________________________

Degree Received _______________________________ Date Conferred ________________________

**********************************************************************************
Awards, Achievement, Extra-curricular Activities Which Have Contributed to Your Preparation for
Teaching:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Relevant Work Experience During the Last Five Years:

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Brief Summary of Professional Goals:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

List Any Special Hobbies, Talents, Interests:

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Please give a copy of this form to your course professor and /or university supervisor, and also to the school in which you
are conducting a practicum or internship.
 B

School of Education
Tuberculosis Certificate

As a condition of acceptance, every student will submit this form signed by a licensed physician, or
registered nurse, stating said student is free from tuberculosis. The certificate is to be based on
recorded results of x-rays, skin tests, and other examinations, singly or in combination, as deemed
necessary by the physician that have been performed.

To be completed by student:

Name___________________________________________________________________

Address_________________________________________________________________

Phone Number___________________________________________________________

Signature_______________________________________ Date_____________________

To be completed by Physician
I hereby certify that on the basis of skin tests, x-rays, and other examination, singly or in combination,
the above named person appears to be free of communicable tuberculosis.

Dates of skin tests, x-rays, and other examinations _______________________________

________________________________________________________________________

Signature_____________________________________________

Printed Name___________________________________________

Address_________________________________________________________________

________________________________________________________________________

______ I am a licensed Physician in _________________________ (state)

______ I am a Registered Nurse licensed pursuant to Virginia’s Board of Nursing.

Please return this form to the Coordinator of Licensure Programs

FAX: 266.4147
 C

SCHOOL OF EDUCATION

PRACTICUM PLACEMENT REQUEST FORM

THIS FORM IS FOR ALL SCHOOL DIVIDIONS OTHER THAN VIRGINIA BEACH AND
NORFOLK. (Please complete the appropriate form for these school divisions).
Deadlines: February 1 for Summer April 1 for Fall October 1 for Spring
Use BLACK ink and PRINT clearly.

PLACEMENT INFORMATION FROM THE TEACHER CANDIDATE

Teacher Candidate’s Name________________________________________________________
Phone______________________________ E-Mail__________________________________
Local Address__________________________________________________________________
(Street) (City) (State) (Zip Code)
Course Title(s) _____________________________________________________________________
Professor/Instructor(s) _______________________________________________________________
Grade Level Requested_______________________________________________________
Dates Requested____________________________________________________________________
(Beginning) (Ending)
Briefly explain any special requests: ____________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________
Total Number of Hours______________________

I understand that confidentiality is a legal issue, and I agree not to discuss my experience in a manner that will allow
identification of any individual. I will contact the school in advance to arrange a mutually convenient schedule.
___________________________________________
Teacher Candidate’s Signature Date
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
INFORMATION FOR THE TEACHER CANDIDATE
* All practicum requests must be coordinated through the School of Education.
* This practicum request will be used for the entire semester, and will be used for all practicum courses that the
teacher candidate is registered for in that given semester.
* It is the teacher candidate's responsibility to obtain enough hours for each practicum course. For example, 15
hours are needed for each practicum course.
* It is the teacher candidate's responsibility to meet the specific requirements for each practicum course. Please
see the syllabus and/or contact the professor for such requirements.
* Grade levels, schools, and teachers may be requested. However, please realize that not all requests can be
honored.

FOR PLACEMENT COORDINATOR'S USE ONLY

Teacher Candidate is currently registered for the following courses:____________________________
Teacher Candidate meets all necessary requirements for placement: _______
Placement Coordinator's Signature_______________________________ Date______________
Date Sent to School District for Placement __________________________________________
Date Placement Received from School District _______________________________________
Date Teacher Candidate Notified of Placement _______________________________________
 D

School of Education
Teacher Preparation Program Pre K-6
Observation Evaluation

________________________ _____________________ __________________

Teacher Candidate’s Name Social Security Number Home Phone #

________________________ _____________________ __________________

School Principal Subject/Grade

________________________ _____________________ __________________

Course Title & Number Semester Instructor

This placement must total _______ hours or more; the Teacher Candidate should obtain a wide
variety of observations with primary emphasis on participation in the classroom.

Time Verification: Please record time to the nearest half hour. Each time block requires a verifying teacher’s signature.

Date Hours/Minutes Grade/Subject/Other Teacher’s Signature

Total Hours: ____________

__________________________________ _________________________________________
Teacher Candidate’s Signature Signature of Principal/Assistant Principal

Observation and Participation Response Record

Below are several characteristics that have some relationship to success in teaching. Please evaluate the Teacher Candidate
by rating him/her in each category. Only respond to characteristics that apply to this observation period.

Characteristics Yes No Not Applicable

Good
Attendance/Promptness
Professional
appearance
Appropriately
courteous to faculty,
staff, & students
Ability to establish
good rapport with
students
**If you have noted any particular strengths or weaknesses please comment:
___________________________________________________________________________________________________
_______________________________________________________________________________________
Check One:
_________ I recommend that this Teacher Candidate continue in his/her teacher education program.
_________ I do not recommend that this Teacher Candidate continue in his/her teacher education program.

Please mail this completed form to:

School of Education
Regent University
1000 Regent University Drive
Attn: ADM 266, Coordinator of Licensure Programs
Virginia Beach, VA 23464
 E

Practicum Evaluation
Teacher Preparation PreK-6

To Be Completed by the Assigned Clinical Faculty

Practicum Dates: From: ________ To: __________ Semester/Year: ______________
Course Title & Number: ________________________________ Instructor: ________________________________
Teacher Licensure Candidate: ____________________________ Home Phone: ______________________________
Check one: Undergraduate ‫ٱ‬ Graduate ‫ٱ‬ Licensure Only: ‫ٱ‬

Clinical Faculty___________________________________ Grade_________ Subject_______________

School District____________________________________ School______________________________

Please evaluate this teacher licensure candidate on the basis of his/her potential for teaching based on performance in your
classroom using the following scale:
4 = Exceeds Expectation 3 = Meets Expectation 2 = Needs Improvement 1 = Unacceptable
4 3 2 1
1. Personal Conduct
Well-groomed and appropriately dressed
Reliable, dependable and punctual
Shows initiative and willingness to assume responsibility
2. Communication Skills
Uses oral communication skills effectively
Uses written communication skills effectively
3. Relationship with District Staff, School Staff and Parents
Tutoring (one-on-one)
Small group instruction
Large group instruction
Helping with special projects
4. Teaching Plans and Materials
Plans activities that are appropriate to stated objectives and learning needs of students
Plans lesson procedures in detailed manner
Reviews and modifies plans as necessary to teach effectively
5. Classroom Management and Interaction
Maintains focus on the lesson plan
Handles disruptions effectively
Follows recognized class procedures
6. Classroom Instruction Practices
Presents a structured lesson: reviews concepts and skills, states, objectives, and
provides meaningful activities
7. Feedback to Students
Includes appropriate evaluation in lesson plans
Develops and implements tests
8. Demonstration of Content Knowledge
Demonstrates knowledge and skill in major subject areas
9. Impact on Student Learning
Monitors activities and evaluates progress during instruction through questioning,
observation, checking work, and assessment of the learning objectives
4 3 2 1
__________________________________ ____________________________________
Signature of Clinical Faculty Date Signature of Regent Faculty Date

Please mail this completed form to:

School of Education
Regent University
1000 Regent University Drive
Attn: ADM 266, Coordinator of Licensure Programs
Virginia Beach, VA 23464
 F

1000 Regent University Drive

Virginia Beach, VA 23464

Clinical Faculty STIPEND Form

(Internship)

This form should be completed by the individual who is designated as the clinical faculty.
Please return the form to Regent University, School of Education, 1000 Regent University Drive, Virginia
Beach, VA 23464-9800. ATT: Dr. Carla Bergdoll, Coordinator of Licensure Programs.

Name of Clinical Faculty _________________________________________________________________

Last First Middle

Address ________________________________________________________________________________
Street City State Zip

Social Security Number __________________________________________________________________

Home Phone Number ______________________ Work Phone Number _____________________

Email Address ___________________________________________________________________

School Name and Address __________________________________________________________

School Division __________________________________________________________________

Name Of Teacher Candidate ________________________________________________________

Signature of Clinical Faculty _______________________ Date ___________________________

FAX: 226.4147
 G

1000 Regent University Drive

Virginia Beach, VA 23464

Clinical Faculty Information Form

(Practicum)

This form should be completed by the individual who is designated as the clinical faculty.
Please return the form to Regent University, School of Education, 1000 Regent University Drive, Virginia
Beach, VA 23464-9800. ATT: Dr. Carla Bergdoll, Coordinator of Licensure Programs.

Name of Clinical Faculty _________________________________________________________________

Last First Middle

Address ________________________________________________________________________________
Street City State Zip

Social Security Number __________________________________________________________________

Home Phone Number ______________________ Work Phone Number _____________________

Email Address ___________________________________________________________________

School Name and Address __________________________________________________________

School Division __________________________________________________________________

Name Of Teacher Candidate ________________________________________________________

Signature of Clinical Faculty _______________________ Date ___________________________

FAX: 226.4147
 H

School of Education
Elementary Education PreK-6 Licensure Program

Internship Application
Deadline for Application: April 1 for fall term. October 15 for Spring term February 1 for summer term

Personal and Professional Information (Please PRINT clearly)

Name________________________________________________ SSN_______________________________________________

Address________________________________________________City/State/Zip ______________________________________

Phone (home) ____________________ (work) __________________ (cell) ____________ Regent E-mail ___________________

Internship Information

Preferred School District & School Name (1st 8 week placement) ____________________________________________________
Preferred School District & School Name (2nd 8 week placement) ____________________________________________________

Clinical Faculty Request (1st 8 week placement) __________________________________________________________________

Clinical Faculty Request (2nd 8 week placement) _________________________________________________________________

*NOTE: If you are working in a school as an aide or other paraprofessional and would like to do your internship experience in the same
school, please note that above. Indicate the school, appropriate contact person in authority, and the name of the teacher with whom you
would like to work.

Period of semester: Semester________________ Year_____________________

Grade-Level Preference (rank 1-3) PreK-3 Elementary_____ 4-5 Elementary_____ 6 Middle___________

Courses you will take in conjunction with student teaching__________________________________________________________
Program completion date______________

A Placement WILL NOT be processed until the following items are on file in the Coordinator of Licensure Programs office:

Have you obtained Liability Insurance? __________ Please provide copy of policy.

Have you completed a background check? ________ Please provide notarized verification.

Have you obtained a TB test? ________________ Please provide verification.

Passing Scores on Praxis I ________________

Teacher Candidate’s Signature_________________________________________ Date_________________

For Administrative Use ONLY:

School Division ______________________________ School Name ______________________________ Grades ____

Clinical Faculty Name(s) _____________________________________ Dates of Internship________________________

Verification of all required documentation _____________

Deadline for Application: April 1 for Fall October 15 for Spring February 1 for summer

(10.6.04)
 I

SCHOOL OF EDUCATION

Teacher Candidate's Self-Evaluation of Field Experience (practicum or internship)

Teacher Candidate's Name: _____________________________________ Dates of Placement: ________________

Clinical Faculty's Name: ________________________________________ School: ___________________________

Professor: ____________________________________________________ Course/Semester: __________________

Complete the evaluation of your field experience. The intent of this evaluation is to serve both as a self-
examination of your growth and also as a means of helping faculty members improve the teacher preparation
program at Regent University. Return your completed evaluation form to your field experience professor or
university supervisor.

During this field experience, my performance Below Meets Exceeds in

each of the following areas was… Expectations Expectations Expectations

Punctuality

Dependability

Organization and Preparation

Communication Skills

Appearance and Dress

Effort and Initiative

Cooperativeness and Flexibility

Enthusiasm

Attention to Student Safety

Contribution to a Positive Learning Environment

Rapport with Students

Rapport with Parents and Other Community Members

Rapport with Faculty and Other School Personnel

Professional Demeanor

Reflection upon Practice

Potential for Leadership

Based on your experiences and coursework to date, please provide a written evaluation of your strengths,
weaknesses and development in becoming an effective teacher. (Attach a separate sheet, if necessary.)
_______________________________________

Teacher Candidate’s Signature Date

 J

SCHOOL OF EDUCATION
Internship --Weekly Evaluation of Teacher Candidate by Clinical Faculty

Teacher Candidate's Name: _____________________________________ Date: _____________________________

Clinical Faculty: _______________________________________________ School: ___________________________

This form has been designed to help clinical faculty give the teacher candidate frequent specific feedback. After checking the applicable
items in each area, please turn the page and provide specific information regarding strengths and areas for improvement.

PROFESSIONAL ATTRIBUTE SCALE

1. Attendance 2. Punctuality 3. Oral Expressions
___ Frequently absent ___ Frequently late ___Makes frequent usage/grammatical errors
___ Rarely absent ___ Generally punctual ___ Inarticulate
___ Exemplary attendance ___ Always on time ___ Articulate
___ Expressive, animated

4. Written Expression 5. Tact/Judgment 6. Reliability/Dependability

___ Written works demonstrate frequent misspellings
and/or grammatical errors
___ Writing is often unclear or disorganized
___ Organizes and clearly expresses ideas
___ Frequently and effectively communicates with
parents and/or administrators
___ Thoughtless: Insensitive to others' feelings ___Sometimes fails to complete assigned tasks
and opinions and duties
___ Limited sensitivity and diplomacy ___ Sometimes needs to be reminded to attend
___ Perceives what to do or say in order to to assigned tasks or duties
maintain good relations with others and ___ Responsible: Attends to assigned tasks or
and responds accordingly duties
___ Highly sensitive to others' feelings and ___ Self-starter: Perceives needs and attends to
opinions: Diplomatic them immediately

7. Self-Initiative/Independence 8. Collegiality 9. Relating Theory to Practice

__ Passive: Depends on others for direction, ideas
and guidance
__ Has good ideas, works effectively with limited
supervision
__ Creative and resourceful: Independently
implements plans
10. Response to Feedback
___ Unreceptive to feedback
___ Receptive - BUT doesn't implement suggestions
___ Receptive - AND adjusts performance
accordingly
___ Solicits suggestions and feedback from others
___ Prefers to work in isolation
___ Reluctant to share ideas and materials
___ Prefers being part of a team
___ Willingly shares ideas and materials
11. Interaction with Students
___ Sometimes antagonistic towards student
___ Shy: Hesitant to work with students
___ Relates easily and positively with students
___ Outgoing: Actively seeks opportunities to
work with students
___ Accepts responsibility for student learning
___ No evidence of implementing pedagogical
theories
___ Sometimes relates theory to practice
___ Frequently bases practical work on sound
pedagogical theory
12. Interaction with School
Faculty/Staff
___ Is sometimes antagonistic
___ Shy: Hesitant to work with school personnel
___ Relates easily and positively
___ Outgoing: Actively seeks opportunities to
work with school personnel

INSTRUCTIONAL DEVELOPMENT SCALE. Summarize the proficiency level for each area listed. Identify at least two areas of instructional
strength your teacher candidate demonstrated this week (Indicate with a "+"). Then identify at least two areas that the teacher candidate needs to focus on
for the following week (Indicate with a "√"). After checking items in each area, please turn the page and provide more specific information.

Teaching Plans and Materials

1. Plan has objectives for current lesson □ 15. Collects, reviews, and grades homework, and links to classroom instruction □
2. Plan has objectives related to appropriate SOL (if applicable) □ 16. Begins lesson on schedule □
3. Plan is suitable for diverse learners □ 17. Uses student responses and questions in teaching □
4. Plan has procedures for regularly assessing student progress and □ 18. Uses appropriate wait time for students after asking questions □
making adjustments 19. Uses effective closure or summarization techniques □
5. Plans are given to clinical faculty in advance □ 20. Uses instructional time effectively □
Classroom Management, Interaction and Feedback 21. Content information is accurate and current □
6. Provides behavioral expectations at beginning of lesson □ 22. Students are asked higher order questions □
7. Reinforces appropriate student behavior □ 23. Effectively incorporates technology into instruction □
8. Demonstrates enthusiasm for teaching □ Impact on Student Learning
9. Provides feedback to students about behavior □ 24. Student learning is evidenced by frequent work samples □
10. Maintains positive classroom behavior □ 25. Student learning is evidenced by active engagement in class □
11. Encourages students when they have difficulty □ 26. Student learning is evidenced by positive social interactions with peers
Classroom Instructional Practice and Content Knowledge and school personnel □
12. Starts lesson from a point of engagement □ 27. Student learning is evidenced by high rate of correct responses and13.
Provides objectives and establishes student's prior knowledge □ successful performance on quizzes and tests (See Next Page) □
14. Provides opportunities for students to be actively engaged □
 K

WEEKLY FEEDBACK GUIDE (continued)

If there are elements of professional development or instructional development competencies that need more
attention, please provide specific examples of how the teacher candidate may strengthen these areas.

______________________________ _____________________
Clinical Faculty Signature Date Teacher Candidate Signature / Date

In the space below, the teacher candidate will briefly outline plans to strengthen or improve areas noted
above by the clinical faculty.
 L

SCHOOL OF EDUCATION

Report of University Supervisor’s Internship Observation and Conference

Teacher Candidate's Name: _____________________________________ Date of Visit:_______________

Clinical Faculty's Name: _______________________________________ School: ___________________

Date/Time of Next Visit: _________________________________________________________________

Lesson Plan Comments

__________________________________________________________________________________________
_______________________________________________________________

Weekly Journal Review

__________________________________________________________________________________________
______________________________________________________________

Observations:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

Went well: Do differently:

Strengths: Refinement:

Focus for next observation: _______________________________________________________________

______________________________________________________________________________________
______________________________________________________________________________________
__________________________________ __________________________________
Signature of Teacher Candidate Date Signature of University Supervisor Date
 M

School of Education
Internship Evaluation: Midterm / Final by Clinical Faculty

Name of Teacher Candidate_________________________________________________________

Endorsement Area______________________________________ Age/Grade________________
Level__________________________________________________________________________

Internship Dates:
Began___________________________________Concluded______________________________
School__________________________________ District________________________________
State___________________
Evaluator’s Name_____________________________________________
Evaluator’s Position___________________________________________

Please rate the teacher candidate’s performance according to the following rubric:
5 = Outstanding 4 = Above Average 3 = Satisfactory
2 = Needs Improvement 1 = Unsatisfactory 0 = No Opportunity to Observe

I. Instructional Planning and Delivery

1. Uses formal and informal assessment data to make instructional decisions.
012345
2. Plans instruction based on objectives and core curriculum demands.
012345
3. Designs instruction that academically addresses learning style and motivation,
as well as behavioral and academic needs.
012345
4. Plans instruction based on diagnostic teaching.
012345
5. Designs instruction that includes review, teacher presentation, guided and
independent practice, immediate feedback and delayed testing.
012345
6. Designs and implements instruction that facilitates retention and transfer.
012345
7. Involves students with daily visual charting of academic and behavioral performance.
012345
8. Demonstrates effective use of instructional time.
012345
9. Uses relevant example and demonstration to illustrate concepts and skills.
012345
10. Makes efficient transitions between instructional activities.
012345
11. Summarizes the main points at the end of the lesson.
012345
12. Incorporates all language modes in instructional planning and delivery.
012345
13. Uses signals, cues, and questioning appropriately.
 N

012345
14. Conducts and uses task analysis.
012345
15. Integrates effective social skills, as well as career and vocational skills with
academic curricula.
012345
16. Uses computer technology when appropriate.
012345
17. Uses research-based instructional approaches and techniques.
012345
Comments:

II. Management
A. Behavior
1. Utilizes a predetermined set of behavior management rules and procedures.
012345
2. Anticipates behavior problems (signals, behavioral indicators) and responds.
012345
3. Designs and implements appropriate behavior intervention plans.
012345
4. Designs and implements strategies for social skill instruction.
012345
5. Uses knowledge about students to prevent behavior problems.
012345
Comments:

B. Instructional
1. Utilizes an established set of rules and procedures that govern the
handling of routine administrative matters.
012345
2. Plans and directs the activities of a classroom paraprofessional, aide,
volunteer, or peer tutor.
012345
3. Arranges classroom environment for effective learning.
012345
Comments:

III. Communication
 O

1. Uses voice tone and facial expressions for emphasis, management, and expression.
012345
2. Actively listens and appropriately responds to students, parents, teachers, and
administrators, and other school personnel.
012345
3. Collaborates with parents, classroom teachers, and other school/community personnel.
012345
4. Communicates specific information on student performance to teachers,
administrators, parents, and other school professionals.
012345
5. Chooses language appropriate to learner needs.
012345
6. Builds an interactive learning community with students.
012345
7. Demonstrates ability to problem solve as well as manage resistance
and conflict in interactions with students and professionals.
012345
8. Writes appropriate goals and objectives.
012345
9. Understands and respects individual differences.
012345
Comments:

IV. Evaluation and Assessment

1. Examines student educational files and understands and utilizes assessment data.
012345
2. Conducts and analyzes functional assessment of behavior.
012345
3. Uses direct observation techniques to gather data and design behavioral interventions.
012345
4. Conducts diagnostic assessment for instructional purposes.
012345
5. Monitors daily academic progress.
012345
6. Provides immediate feedback.
012345
7. Sequences, implements, and evaluates individual learning objectives.
012345
8. Critiques daily performance.
012345
9. Keeps anecdotal record of student behavior.
012345
Comments:

V. Professional and Ethical Behavior

 P

1. Plans and directs activities of classroom assistants including paraprofessionals,

volunteers, and tutors.
012345
2. Modifies performance based on personal and professional critiques.
012345
3. Demonstrates flexibility.
012345
4. Demonstrates initiative in planning, management and professional interactions.
012345
5. Maintains confidentiality.
012345
6. Demonstrates effective collaboration in one-to-one and small group interactions.
012345
7. Fosters trust in relationships with students, families and colleagues.
012345
8. Receives and responds to constructive feedback.
012345

Comments:
 Q

Summary:

______________________________________
Signature of Evaluator Date

______________________________________________
Signature of Teacher Candidate Date

1000 Regent University Drive

Virginia Beach, VA 23464
(757) 226-4479
 R

School of Education
Internship -- Evaluation of Teacher Candidate by School Administrator
Teacher Candidate ________________________________ Date______________________
Semester ________________________________________
School Division___________________________________ School____________________
School Administrator_______________________________
Description of School: 1. Urban ( ) 2. Suburban ( ) 3. Rural ( )

Please rate the teacher candidate on each item using the following scale:

E = Excellent S = Satisfactory N = Needs Improvement NA = Not Applicable

E S N NA

I. Personal Characteristics and Professional Attitudes

II. Knowledge of Subject Matter

III. Planning

IV. Instruction

V. Management and Control

VI. Team Interaction

VII. Assessments

Areas of Strength:

Areas for Refinement:

Signature of School Administrator:____________________________________________________

Date:_____________

Signature of Teacher Candidate:________________________________ Date:_____________

 S

Semester/Year ___________

Internship -- Clinical Faculty Feedback

Please answer the following questions so that we can assess and improve the teacher
preparation program at Regent University. Your input is of great value and we plan to
take your recommendations into thoughtful consideration as we seek ways to improve
our program.
1. Was our teacher candidate adequately prepared for the placement?

a) In what areas was the teacher candidate sufficiently prepared?

b) In what areas could he/she have been better prepared?

2. Was the university supervisor sufficiently involved in the internship experience?

3. Would you be willing to serve again as a clinical faculty?

4. Do you have any other comments or recommendations?

Clinical Faculty Signature____________________________________________________________

Public School:_______________________________________________________________________

Date: __________________

Thank you once again for your time and your input. Please FAX this form (266.4147) to Regent
University, School of Education.
 T

School of Education

INTERNSHIP -- CLINICAL FACULTY EVALUATION

Teacher Candidate’s Perspective

Clinical Faculty’s Name __________________________________ Semester/Year ___________

Teacher Candidate’s Name ________________________________

Please indicate to what degree your clinical faculty performed the listed activities by circling the
appropriate number using the following scale:

4 = Exceeds Expectations 3 = Meets Expectations 2 = Needs Improvement 1 = Unacceptable 0 = Not Observed

I. SUPPORT/COMMUNICATION

• Acquainted you with the school, staff, students, teachers, parents and 4 3 2 1 0
community
• Oriented you to classroom rules, organization, and management 4 3 2 1 0
• Supported you by providing a strong professional relationship with 4 3 2 1 0
you the teacher candidate

II. INSTRUCTIONAL GUIDE

• Provided a positive learning environment 4 3 2 1 0

• Provided a desk or work place, necessary instructional materials 4 3 2 1 0
resources, supplies and equipment
• Guided you with initial lesson plans and material development 4 3 2 1 0
• Modeled how to maintain grades, lesson plans, and assess students 4 3 2 1 0
• Acquainted you with routine tasks 4 3 2 1 0

III. PROFESSIONAL GROWTH

• Provided opportunities for observation/participation in related school 4 3 2 1 0

events

IV. SUPERVISION/ASSESSMENT

• Analyzed and critiqued teaching technique regularly 4 3 2 1 0

• Provided continuous support, conferences, and feedback (written and 4 3 2 1 0
verbal)
• Identified specific areas of strength and weakness 4 3 2 1 0

Comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please return this form to the School of Education Office / Dr. Wighting.
 U

School of Education

INTERNSHIP -- UNIVERSITY SUPERVISOR EVALUATION

Teacher Candidate’s Perspective

University Supervisor’s Name __________________________________ Semester/Year ___________

Teacher Candidate’s Name _____________________________________

Please indicate to what degree your university supervisor performed the listed activities by circling the
appropriate number using the following scale:

4 = Exceeds Expectations 3 = Meets Expectations 2 = Needs Improvement 1 = Unacceptable 0 = Not Observed

I. SUPPORT/COMMUNICATION

• Advised you of the requirements at the beginning of the semester 4 3 2 1 0

• Was accessible by phone and/or email 4 3 2 1 0
• Agreed to visit you when assistance was needed 4 3 2 1 0
• Derived a workable solution if difficulties occurred 4 3 2 1 0
• Provided relevant information through seminars, workshops, 4 3 2 1 0
counseling, etc.
• Reviewed weekly journal and provided feedback when needed 4 3 2 1 0
• Discussed development and implementation of lesson plans 4 3 2 1 0
• Reviewed your portfolio and provided feedback on a regular basis 4 3 2 1 0

II. SUPERVISION/ASSESSMENT

• Coordinated visit dates/times with clinical faculty 4 3 2 1 0

• Spent ample time (50-60 minutes) for observation/assessment 4 3 2 1 0
• Analyzed and critiqued teaching technique soon after observation 4 3 2 1 0
• Helped you to identify specific areas of strength and weakness 4 3 2 1 0
• Previewed and discussed the purposes of each evaluation form 4 3 2 1 0
• Reviewed with you the results of each evaluation 4 3 2 1 0
• Conducted a three way conference with teacher candidate intern 4 3 2 1 0
and clinical faculty
• Conducted all conferences in a positive and constructive manner 4 3 2 1 0

Number of visits each placement ___________

Comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please return this form to the School of Education / Dr. Wighting.
 V

School of Education
Elementary Education Licensure Program
Internship Time Log
Teacher Candidate's Name _______________________________________________________________

#1 Clinical Faculty's Name/School _________________________________________________________

#2 Clinical Faculty's Name/School _________________________________________________________

Semester/Year ____________________________

Hours
Student Contact Non-Student Total
Start Date through End Date Contact
Clinical Faculty's
Signature

Week of
Week of
Week of
Week of
Week of
Week of
Week of
Week of
Week of
Week of
Week of
Week of
Week of
Week of
Week of
Week of
TOTAL

#1 Clinical Faculty's Signature ____________________________________ Date _________________

#2 Clinical Faculty's Signature ____________________________________ Date _________________

Signature of Teacher Candidate ___________________________________ Date _________________

 W

School of Education
Completion of Internship
Teacher Candidate Name _____________________________________________________
Semester/Year______________________

University Supervisor Name ___________________________________________________

Placement 1 Placement 2

* Mid Term Evaluation □ * Mid Term Evaluation □

* Final Evaluation □ * Final Evaluation □

* Administrator's Evaluation □ * Administrator's Evaluation □

Weekly Journal □ Weekly Journal □

Portfolio □ Portfolio □

* Time Log □ * Time Log □

This teacher candidate has □ Passed □ Failed the Internship.

Signature of University Supervisor: ____________________________________________________

Date: ________________________

* Please attach copies of this form.

University Supervisors, please return this form with all attachments to the Field Placement
Officer on conclusion of the internship.