Diversity 4b Form
Current Status:
Intern Name:
Intern Email:
Major(s):
Today's Date: 11/29/2014 12:27:39 AM

Identify Diverse Faculty/Clinical Educator

For accreditation purposes, the Office of Field Experiences is compiling information on your interaction with diverse peers over time. Prior to student teaching, self report your experiences working with diverse Faculty/Clinical Educator in your classes or through other experiences during your program of study.

Ethnicity/Race 1
Identify Ethnicity/Race if known 1:
Name of Faculty/Clinical Educator:
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):
Ethnicity/Race 2
Identify Ethnicity/Race if known 2:
Name of Faculty/Clinical Educator:
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):
Gender (at least 2 male and 2 female faculty)
Name of Faculty/Clinical Educator:
Name of Faculty/Clinical Educator:
Name of Faculty/Clinical Educator:
Name of Faculty/Clinical Educator:
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):
English Language Learner (ELL) at least 1 ELL faculty
Name of Faculty/Clinical Educator:
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):