Diversity 4c Form
Current Status:
Intern Name:
Intern Email:
Major(s):
Today's Date: 11/26/2014 11:54:33 PM

Identify Diverse University Peers

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 peers in your classes or through other experiences during your program of study.

Ethnicity/Race 1
Select a Race or Ethnic Group (other than your own) with whom you have had experience(1):
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):
Ethnicity/Race 2
Select a Race or Ethnic Group (other than your own) with whom you have had experience (2):
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):
Gender
Which gender(s) did this experience involve?
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):
Diverse Socioeconomic Groups
Did this experience include diverse socioeconomic groups?
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):
Candidate with Exceptionalities
Did this experience include a candidate with exceptionalities?
Semester and Year:
School(s) or Sites(s):
Identify Type of Experiences (Select all that apply):