Clinical Experience Diversity Report

Please provide your Longwood ID (L_Number): [Help]

NOTE: You MUST provide your correct Longwood ID in order for this form to be processed.

Please provide your name as you are currently enrolled at Longwood:

Last Name

First Name

Middle Name or Middle Initial

Please indicate on which of the following you are reporting information: [Help]

		Practicum II		Graduate Professional Internship (EDUC 689)
		Student Teaching Placement 1		Partnership
		Student Teaching Placement 2		Graduate Supervised Experience in Library Services
		Graduate Practicum II (EDUC 679)		Other Placement

Please indicate the semester and year in which you are participating in this experience:

Semester

Year

		Yes
		No

Are you on the New College Institute campus?

INSTRUCTIONS FOR COMPLETING THE REST OF THIS REPORT: The information requested on the following page of this report should be based on the students and classroom in which you were placed. It is used by Longwood to ensure that Longwood students are given the opportunity to work with a variety of PreK - grade 12 students and teachers in a variety of settings, so please be as accurate as possible. If you are uncertain about how to answer particular questions, please consult with your Longwood instructor, the classroom teacher, or university supervisor for guidance. You can save your responses at any time and then return to complete this report at a later time.