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2.19 Step Three Report for Provisional Supervisor-Educator (PSE) Report ©

Personal Information: (please type or print)
Provisional Supervisor-Educator:
SPE Stream: / CPE / PCE
Certified Supervisor-Educator:
Teaching Site Offering Unit:
Site Address:
Period of Education: / / / to / /
DD MM YY DD MM YY

Candidate:

I certify that I am currently not under investigation or in an appeal process regarding an alleged violation of the Code of Ethics and Professional Conduct of CASC.

Candidate’s Signature: Date:

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Review Team Information:

Chair’s Name (print): / Certification:
Member Name (print): / Certification:
Member Name (print): / Certification:

Interview Report: 1st Interview 2nd Interview

Date of Interview:

Location (provide full address):

Length of Interview:

Interview Outcome: (select one only)

Overall Professional Competence Indicators were sufficiently demonstrated; the candidate is recommended for Provisional education standing.

Recommendations/Goals for Provisional Supervisor-Educator (use an additional sheet of paper if necessary):

Overall Professional Competence Indicators were not sufficiently demonstrated. The candidate may return within 8 weeks.

Date, time and location of the second interview, as negotiated between the Review Team and the Candidate:

Overall Professional Competence Indicators were not sufficiently demonstrated, and the request for

Provisional education standing is denied.

Recommendations (use an additional sheet of paper if necessary):

Please provide Name and Signature
Chair (print name): / Chair (signature):
Member: (print name): / Member: (signature):
Member: (print name): / Member: (signature):

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Candidate:

I have received all copies of my written materials back from the Review Team members.

I have received and read the assessment and recommendation of my Review Team. I understand that the Review Team’s decision will be reported to the CASC’s Education Standards Commission. I understand that a copy of this report will be secured in my national office file for as long as I am a member of CASC plus one year.

Candidate’s Signature: / Date:
Regional Admitting Chair (RAC):
RAC Signature: / Date received:

Revised October 2017 Posted December 2017, 2.19 Page 1 of 2