Fillable FillableStmtofExperience-SPED5-15 Central Connecticut State University

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FillableStmtofExperience-SPED5-15 Central Connecticut State University

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Central Connecticut State University (CCSU)
School of Education and Professional Studies
New Britain, CT 06050
SPECIAL EDUCATION PROGRAM
VERIFICATION OF EXPERIENCE IN SCHOOLS FORM
Before applying for acceptance into the professional program, you are required to complete a
total of forty (40) hours of experience in a public school setting. Thirty (30) hours of this
experience must consist of observations in regular education settings and ten (10) hours of
experience must be done in special education settings. These observations might consist of:
1. Direct observation of students
2. Shadowing of administrator or related services staff member
3. Tutorial/aide/paraprofessional/volunteer worker
You may need to complete more than one of these forms. A principal or person
supervising your experience must complete and sign below. Attach this form to your
Professional Program application.
Applicant Name: _______________________________________ Banner ID: _____________
Principal or supervisor verification:
I certify that (student’s name) __________________________________ has completed (check
one or both of the following):
Thirty (30) hours or ____ hours of experience in this regular education setting.
Ten (10) hours or ____ hours of experience in this special education setting.
Signature of Principal or Supervising Person:_________________________________________
Print Name:____________________________________Title:___________________________
School and District:______________________________________________________________
Phone Number of School:_________________________________________________________
revised 5/02015
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FillableStmtofExperience-SPED5-15 Central Connecticut State University

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Completed 7 March 2020

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