Student Name: _________________________________ Semester/Year: _____________ Major/Level:_____________
Directions: The student named above has been nominated as a potential candidate for an internship. Please complete, sign and
return to the Director of Certification.
A. Check all settings listed in which you have observed the applicant.
_____ Observation and Participation in class
_____ Demonstration of a lesson or presentation in a methods course
_____ Pre-Student Teaching Clinical Experience Lesson
_____ WLC course(Course name/number): _______________________________________________________________________
_____ WLC course in which student has presented: (Name/Number) ___________________________________________________
_____ Other(briefly describe):
B. Using the following, check the number that best applies to the applicant. If you have not observed the applicant for a
category, check “n/o.” Use the following rating scale: 5 = Exceeded Expectations 4 = Met Expectations
3 = Approached Expectations 2 = Below Expectations 1 = Not Acceptable
5 4 3 2 1 n/o
Initiative: Takes initiative and works with minimal supervision. Comments:
Respect: Classmates respect the applicant. Comments:
Teaching Ability: Demonstrates skill and effectiveness as a potential teacher in formal and/or informal
teaching/presenting situations. Comments:
Enthusiasm: Demonstrates enthusiasm for teaching in formal or informal situations. Comments:
Applicable experiences: Working with children/youth has prepared this candidate for a teaching Intern-
ship; has demonstrated a willingness to do more than the usual clinical requirements in effort, hours and
involvement. Comments:
Total Score: Average:
C. What specific characteristics does the applicant have that may contribute to the person’s effectiveness as an intern?
D. What characteristics, if any, does the applicant demonstrate that may deter that person’s effectiveness as an intern?
E. Check ONE number that best represents your recommendation of this applicant as an intern.
___4: Highly recommend ___3: Recommend ___2: Recommend w/qualification ___1: Do NOT recommend
Signature: _______________________________________________ Date: _______________________________
TEACHER INTERNSHIP SELECTION FORM
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