(Over, please)
SCHOOL OF EDUCATION
Field Supervisor/Mentor Information
To maintain our NCATE accreditation, the IU Southeast School of Education must document the background and
expertise of field placement supervisors/mentors for clinical experiences with student teachers, counseling inters,
or leadership protégés. This information is also required to process honorarium for the supervisor/mentor, if
applicable. Your information will be kept confidential.
Please use the back or another sheet if you need more space. You may attach your state’s website report on your
certifications and omit the related questions.
Thank you!
Jane Riehl and Jim Clements, Field Placement Coordinators
A. PERSONAL INFORMATION
Supervisor’s Name: __________________________________________________________________________
Home Address: _____________________________________________________________________________
City_______________________________________ State _______________________ Zip ________________
Email: ____________________________________________________________________________________
Student Teacher’s/ Intern’s Name: ______________________________________________________________
Highest Education Degree (check one): ____ BA/BS ____MA/MS ____+30/Rank 1 ____Ed. D/Ph. D
Institution Granting Highest Degree: ____________________________________________________________
Year Granted: __________________
License(s) Held w/ Certification Area(s):
Years of Teaching Experience: ____________________
Years of Counseling Experience: __________________
Years of Administrative Experience: _______________
Sex: ___Male ___Female
Ethnic Identification:
___ White, non-Hispanic ___Black, Non-Hispanic ___ Asian or Pacific Islander
___ American Indian ___ Hispanic ___Other ______________________________
(Over, please)
B. PROFESSIONAL INFORMATION
Professional Development (ex: Mentor Training):
Service as a Trainer (ex: ISTEP, 4 Block):
Leadership Role(s) in District/Corporation:
Membership/Offices Held in Professional Organizations:
Awards/Recognition Related to Education:
Professional Presentations/Publications (within last 3 years):
Approximate number of clinical experience (student teaching or internships) candidates supervised to date, prior
to this current placement: _______________
Approximate number of early field experience candidates supervised to date (e.g. F200, P250, Methods; NOT
student teaching/internship): _____________
C. SCHOOL INFORMATION
School Name: _________________________________________________________________________
School Description (check one): ___Rural ___Urban ___Suburban
Approximate % of students on Free/Reduced Lunch: ___________
Approximate % of students in school in each race/ethnicity:
Approximate % of ENL/ESL students: ______________
Approximate % of IDEA students: _________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome