Cooperating Teacher Feedback and Data Form
This OPS assignment is:
Practicum I
Practicum II
Student Teaching
Graduate Placement in Library Media
Please complete all blanks. Enter N/A if not applicable.
CONTACT INFORMATION
Ethnic Background
Black, not Hispanic
Hispanic
American Indian
Asian, Pacific Islanders
White, not Hispanic
Other
Name:
Gender
Male
Female
Professional Contact Email Address
School
Subject Area
Grade(s)
School Mailing Address:
Zip / Postal Code:
City:
School Telephone#
Alternate Telephone#
EDUCATION
Name & Location of Institution
Degree Received
Major or Specialty Area
Minor
Dates Attended
1
2
3
4
LICENSE AREAS: Please provide all license endorsement areas that you possess.
TYPE OF LICENSE
ENDORSEMENT AREAS
GRANTED BY
1
2
3
4
Please indicate the years of PROFESSIONAL EXPERIENCE in each category below. (if none, just skip)
None
1 to 5 years
6 to 10 years
10+ years
1 to 5 years
6 to 10 years
10+ years
3-5 years
6-10 years
10+ years
Supervision
Teaching
Administration
What is the approximate percentage of students i
n your school
who have disabilities?
What is the approximate percentage of students
in your school
who are English Language Learners (ESL)?
How many times have you hosted a Longwood student teacher candidate?
What method was used to select you as a cooperating teacher (i.e. volunteer, application, administrator selection).
Please tell us what would have improved this placement or any additional comments you may have.
We appreciate your continued support in our effort to prepare future educators.
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