Northwestern State University s1

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Course:

Instructor:

Student name: Northwestern State University

College of Education

Natchitoches, LA 71497

Field-Based Clinician Questionnaire

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Name: ______

First Middle Last Maiden

School(s): ______

Current Teaching Assignment: ______

Grade Level(s) Subject(s)

Years Teaching at Current School: ______Total Years Teaching:

Fluent in Multiple Languages: □ Yes □ No If yes, list language(s):

Gender: □ M □ F

Race:

□ American Indian or Alaskan Native □ Hispanic

□ Asian or Pacific Islander □ Not Reported

□ Black, Non-Hispanic □ White, Non-Hispanic

□ Foreign/Non-Resident Alien

Certification Type: If you are not sure, please check the Teach LA site (http://www.teachlouisiana.net)

□ Type A □ Practitioner Teacher

□ Type B □ Out of State Provisional Certification

□ Type C □ Out of Field Authorization to Teach

□ Level 1 Professional Certification □ Temporary Authority to Teach

□ Level 2 Professional Certification □ Temporary Employment Permit

□ Level 3 Professional Certification □ Ancillary Certification

Certification Areas: Please check all that apply.

□ Elementary Grades 1-8 □ Vocational Agriculture □ Mild/Moderate

□ Elementary Grades 1-6 □ Vocational Home Economics □ Severe/Profound

□ Lower Elem. Grades 1-4 □ Family & Consumer Science □ Mentally Retarded

□ Upper Elem. Grades 5-8 □ Health □ Learning Disabled

□ Pre K – 3 □ Physical Education □ Academically Gifted

□ Kindergarten □ Health & Physical Ed. □ Library Science

□ Nursery School □ Health, Phys. & Safety Ed. □ School Librarian

□ Early Interventionist (Birth-3) □ Driver Safety & Traffic Ed. □ Media Specialist

□ English □ Aerospace Education □ Guidance Counselor

□ Math □ French □ Counselor in Elementary School

□ General Science □ Spanish □ Counselor in Secondary School

□ Biology □ Journalism □ Supervisor of Student Teaching

□ Chemistry □ Speech . □ Reading Specialist

□ Physics □ Bus/Office Ed. □ Principal (K-12)

□ Physical Science □ Bus Ed. Subjects □ Elementary School Principal

□ Social Studies □ Coop. Office Ed □ Secondary School Principal

□ Instrumental Music □ Computer Literacy. □ Parish/City School Supervisor of Instruction

□ Vocal Music □ Computer Science □ Dir. Parish/City Materials/Media Center

□ Art □ Adult Education Instructor □ School Superintendent

□ Other______

Highest Degree Earned: □ Bachelor’s □ Master’s □ Specialist □ Doctoral

Institution Granting Degree:

Please check all that apply:

□ Supervision of Student Teaching Course □ National Board Certification □ Currently Seeking National Board Certification □ LATAAP Mentor Training □ LATAAP Assessor Training

Revised 06 15 04