LIST OF EXHIBITS FOR STANDARD 3

EXHIBIT 3c.17

Form C

Southeastern Louisiana University  
College of Education and Human Development                                   Hammond, Louisiana  70402

Candidate’s Field-Based Experience Information (CFBEI)*

Part I: To be completed by candidate

Name:_________________  Course #:___________    Instructor:__________________

School/Site:______________  Parish/District:______________________________

Teacher:_________________________________     Grade:_____________________

Date:___  Time in: ____Time out:____                         Date:___  Time in: ____Time out:____

Date:___  Time in: ____Time out:____                         Date:___  Time in: ____Time out:____

Date:___  Time in: ____Time out:____  

Total Time in Field: _____hr.______min.    

Level 1(Observation/Participation):__ Level 2 (Direct Teaching/Tutoring):__  Level 3____          

One-on-one: ___           One-on-one:  ___                                      Student Teaching

Small Group: ___           Small Group: ___                                          

Large Group: ___           Large Group: ___                                          

Part II: Information to be found on Classroom Information form B (FBECI)

Indicate the number of students participating in the classroom activity or being observed.

Breakdown of participants: Please indicate a numerical value for each.

Total Number of Students:__________Male:________Female:___________

Total Number of Students with Exceptionalities:______________

Indicate the number of students participating in the activity.

_____Autism                _____Deaf/Blind          _____ ESL      _____Developmental Delay

_____Gifted                _____Hearing Impairment                     _____Emotional Disturbance

_____Infant and Toddlers with Disabilities                                _____Mental Disability

_____Other Health Impairment (may include ADD)                  _____Multiple Disabilities

_____Specific Learning Disability                                             _____Orthopedic Impairment

_____Speech/Language Impairment                                         _____Talented

_____Traumatic Brain Injury                                                    _____Visual Impairment

_____Temporary Disability (i.e., broken arm, broken leg, etc.)_____Limited Proficiency

Grade Levels: Select the grade(s) of the participants:

_____Early Intervention (Birth to 3)                  _____Pre-K                _____Kindergarten

_____1^st                              _____2^nd                             _____3^rd                    _____4th        

_____4.5                     _____5^th                      _____6^th                     _____7th

_____8^th                      _____8.5                     _____9^th                     _____10th      

_____11^th                   _____12^th                                          

 Ethnicity: Please indicate the number of students for each ethnicity within the class.

_____American Indian or Alaskan Native         _____Hispanic

_____Asian or Pacific Islander                         _____Not Reported

_____Black, Non-Hispanic                             _____White, Non- Hispanic

_____Foreign/Non-Resident Alien       

Part III: To be completed by candidate and signed by the classroom teacher

Subject Observed/Taught: Indicate time spent in each subject

Art/Music                                 ______hrs.       ______min.

Business                                   ______hrs.       ______min.

Foreign Languages                    ______hrs.       ______min.

Health/PE                                 ______hrs.       ______min.

Language Arts                          ______hrs.       ______min.

Mathematics                             ______hrs.       ______min.

Science                                    ______hrs.       ______min.

Social Studies                           ______hrs.       ______min.

Special Education                     ______hrs.       ______min.

Other                                       ______hrs.       ______min.

Specify:_______________________________

TOTAL                                   ______hrs.      ______min.

________________________            ____________ ____________________

Teacher’s Signature                              Date                             Candidate’s Signature                                      

Activity:  A brief summary (four to five sentences) is required for entry into PASS-PORT Description/Reflection:____________________________________________________

NOTE:  To be completed by the candidate and used to enter data in PASS-PORT