OBS #2
Student Name: ____________________________________________________________________________________
last first middle
EDU Course No. __________________________ Course Title ______________________________________________
Dates of Observation: ___________________ (first date) to _________________________ (last date)
(as taken from the log form)
Field Sites (Schools) Hours at Signatures of Cooperating Teachers
each site
_________________________________ __________ ________________________________
_________________________________ __________ ________________________________
_________________________________ __________ ________________________________
Total Hrs. __________
_______________________________ _____________ ___________________________________ _____________
signature of student date signature of EDU Professor date
Are you claiming any of these hours for multicultural hours?
yes no __________ # of MC hours claimed
__________# of MC hours approved
Accumulating Multicultural Hours:
For purposes of clarity, those clinical hours which also count as multicultural hours must be
identified on this form and must be accompanied by a reflection indicating insights, learned experiences and personal assessments of
attitudes gained through this experience. This reflection must be labeled with the following heading: Multicultural Reflection followed
by the number of requested hours. This reflection is reviewed by the course professor and Director of Teacher Education.
________________________________________
Director Initials
DIRECTIONS: Complete one form for each observation requirement. No more than three (3) different sites should be used to fulfill
one (1) requirement. Obtain signatures on the last date of observation at the respective site. (Use a yellow log form to list dates, time
and places which substantiate the summarized information on this form.) Write a summary and reflection of this overall experience.
Submit this summarization/reflection in a TYPED format on the back of this sheet or on an attached sheet.
01/10
OBSERVATION/PARTICIPATION VERIFICATION
PRE-TEACHER CANDIDACY CLINICAL EXPERIENCE
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