Application to Provideclinical Teachingor Internship

APPLICATION TO PROVIDECLINICAL TEACHINGOR INTERNSHIP

OUT-OF-STATE OR IN A U.S. TERRITORY PLACEMENT

Texas Administrative Code (TAC) [19 TAC§228.35(d)(4)(A)]: All Department of Defense Education Activity (DoDEA) schools, wherever located, and all schools accredited by the Texas Private School Accreditation Commission (TEPSAC) are approved by the TEA for purposes of field-based experience, internship, clinical teaching, and/or practicum.

[19 TAC §228.35(d)(4)(C)]:An educator preparation program may file an application with the TEA for approval, subject to periodic review, of a public or private school located within any state or territory of the United States, as a site for an internship or clinical teaching, or practicum required by this chapter.

General Provisions: The clinical teacher or intern candidate must have completed a minimum of 300 clock-hours of coursework, including the curriculum topicsrequired in19 TAC §228.30,and the minimum of 30 clock-hours of field-based experiencesrequired in 19 TAC §228.35(a)(3)(A).For an internship, the candidate must have passed the content examination.

Notice: The contents of this application are confidential to the extent allowed by law.

EPP INFORMATION
EPP NAME:
County District Number:
Contact Person:
Address:
City:State:Zip:
Phone:
Email:Website:
Submission Date: Desired Start Date:

Assurances

The EPP will ensure that the candidate meets all admission requirements prior to formal admission.

The educator preparation program (EPP) will ensure that the cooperating teacher or mentor will possess equivalent content and grade level certification as those being sought by the clinical teacher or intern.

The EPP will ensure, as applicable, that the candidate will experience either:

(1) a clinical teaching experience of a minimum of 12 weeks, full day; or

(2) an internship of one (1) full academic year.

The EPP will ensure that the candidate serving an internship will complete the internship within a period of three (3) years. Each additional year of the internship after the first year must be approved by TEA.

The EPP will ensure that the candidate is supervised by a field supervisor for the extent of the clinical teaching or internship experience.

By September 15th, the EPP will report the candidate in the ASEP system – candidate status list and observations.

______

Signature of EPP RepresentativeTitle

______

Printed Name of AboveDate

Submit one email copy of the completed application, including signed assurances, with a delivery/read receipt .

Insufficient information in any area of the application may delay approval. Approval of this application may take several weeks. Please keep time constraints in mind when submitting the application. There is currently no fee associated with this application.

CANDIDATE INFORMATION
Name of Candidate:
TEA Identification Number:
Certification Being Sought:
Identify one:
Clinical Teaching Grade Level Assignment(s):
Internship Teaching Grade Level Assignment(s): TExAS Passed: Y N
Address:
City:State:Zip:
Phone:
Email:
STATE/ US TERRITORY/ SCHOOL DISTRICT/CAMPUS PLACEMENT INFORMATION
Name of State/U.S. Territory:
Name of School District/Campus:
U. S. Territory/School District/Campus Accreditation(s):
Contact Person:
Address:
City:State: U. S. Territory: Zip:
Phone:
Email:
Website:

In the space below, identify the circumstances that necessitate this request to complete clinical teaching or an internship outside ofthe State of Texas. [19 TAC §228.35(d)(4)(C)]

______military assignment

______illness of candidate or family member

______caretaker of family member

______Other

If other, explain:

In Sections A and Bbelow, provideinformation that aligns the K-12 standards and educator standards of the destinationstate or U.S. territory with the Texas Essential Knowledge and Skills (TEKS) and Texas educator standards for the certificate sought.

Section A: Complete a cross-walk comparison of the instructional standards taught at the destination state/territory/school district/campus with those of the (TEKS) for each grade level within the certification fieldsought. [19 TAC §228.35(d)(4)(C)(ii)]

Applicable TEKS by Content/Grade Level / Destination State/U. S. Territory’s Instructional Standards by Content/Grade Level / For TEA Use Only
A D
A D
A D
A D
A D
A D

Section B: Complete a crosswalk comparisonof the destination state/territory’s content area and pedagogy educator certification standards with the Texas (SBEC) educator certification standards and Pedagogy and Professional Responsibilities standards for the certification being sought. [19 TAC §228.35(d)(4)(C)(ii)]

SBEC Educator Standards and PPRStandards for the Certificate Area/Grade LevelSought. Include all knowledge and skills indicators within each standard. / Destination State/ U.S. Territory’s Correlating Educator Standards and Pedagogy Standards for the Certificate Area/Grade Level Sought / For TEA Use Only
A D
A D
A D
A D
A D
A D

Complete the chart below to describe the Cooperating Teacher or Mentorthat will supportthe clinical teacher or interncandidate.

Program Requirements for Cooperating Teacher or Mentor

[19 TAC §228.35(e) & §228.2(6) & §228.2(14)]

Cooperating Teacher/Mentor Information / EPP Plan for Implementation
Name of Cooperating Teacher or Mentor
(One must be identified prior to application)
Years of teaching experience
(Must be more than three years)
Teaching/professional certification(s) held
(Must match candidate’s)
State issuing certification(s)
Describe training cooperating teacher or mentor has or will receive to support the candidate.
How is the cooperating teacher or mentortraining documented by the program?
Commitment between Cooperating Teacher or Mentor and EPP / EPP Plan for Implementation
Contract or written agreement / Please attach blank copy, if applicable.
Compensation of any type / Yes______N0______
What type of on-going support will be provided to the Cooperating Teacher or Mentor by the EPP?
Expectations of Cooperating Teacher or Mentor / EPP Plan for Implementation
How will he/she communicateand collaboratewith the field supervisor?
Will he/she be required to conduct observations of the candidate? If so, how many? / Yes___ Number____ No_____
How will he/she provide feedback to the candidate?
How will he/she provide feedback to the EPP?

Completethe chart below to describe the Field Supervisor and the supervisionprocess fortheclinical teacher or intern candidate.

Information about Field Supervision [19 TAC §228.35(f) and §228.2(10)]

Field Supervisor Information / EPP Plan for Implementation
Name of Field Supervisor
(One must be identified prior to application and cannot be the same person as the mentor)
Current Educator Certification(s)
Educational Credentials/ Qualifications
Describe the training that has or will be provided to the Field Supervisor.
How will the training be documented?
Commitment between Field Supervisor and EPP / EPP Plan for Implementation
Contract or Written Agreement with EPP / Please attach blank copy, if applicable.
Will the field supervisor be compensated? / Yes______No______
What type of on-going support will be provided to the Field Supervisor by the EPP?
Field Supervision Process / EPP Plan for Implementation
Describe when the initial contact with candidate will be made.
How will the initial contact with the candidate be made? / Face-to-face _____ Email______
Telephone______
When will the first formal observation of the candidate be conducted?
How many formal observations will be conducted for the clinical teacher or intern?
What will be the schedule for the formal observations?
What will be the duration of each formal observation?
How will formalobservations be documented? / Please attach blank copy of form
How will the field supervisor provide feedback to the candidate about the results of the formal observations?
Who will receive copies of the formal observation documentation?
How will additional observations and coaching be documented?
How will the field supervisor communicate and collaborate with the cooperating teacher or mentor?

Provide the clinical teaching phase-in plan from observation to full teach in number of weeks. [19 TAC §228.35(d)(4)(C)]

In the space below, describethe resources that will be available to the clinical teacher or internshould he/she struggle in the teaching experience. [19 TAC §228.35(d)(4)(C)]

In the space below, describe the measures that will be taken by theEPP to ensure that the candidate’s experience will be equivalent to that of a candidate in a Texas public/private school accredited by TEA. [19 TAC §228.35(d)(4)(C)(iv)]

In the space below, provide any other information that may be beneficial in considering this request. [19 TAC §228.35(d)(4)(C)]