Diversity 4.d.2 Form
Data on the Clinical Educator/Cooperating Teacher
Name:
Today's Date: 10/24/2014 1:12:26 AM
School:
Grade/Subject:
Email:
Gender:
Race/Ethnicity (Check appropriate boxes):






Years of Teaching Experience:
Certification Area(s):
Classroom Demographics Data
Enrollment by Gender:
Male:
Female:
Enrollment by Race/Ethnicity:"
American Indian/Alaska Native:
Black or African American:
Asian:
Hispanic:
Pacific Islander:
White:
Other:
Unkown:
Title I Students:
Male:
Female:
Students with Identified Exceptionalities:
Male:
Female:
English Language Learners (ELL):
Male:
Female:
Advanced Level Students (in at least one content area):
Male:
Female:
Low SES (Free & Reduced Lunch Program):
Male:
Female:
Student Teaching Candidate Placement Data
Current Status of Intern (must select):
Intern Name:
Grade/Subject: