Have at least three years of teaching experience in his/her Louisiana certified area of teaching.
Be willing to participate. Complete FORM A, the “Field-Based Teacher Experience Questionnaire” (FBTEQ), before allowing a candidate in his/her classroom. This form is now an online survey and can be completed at www.surveymonkey.com/s/FormA_Fall2013.
Complete FORM B and keep it on site for candidate access.
Southeastern Louisiana University
College of Education
Hammond, LA 70402
*This form is now online at www.surveymonkey.com/s/FormA_Fall2013.
This information requested is used (1) to meet the accreditation requirements of the state and national accreditation agencies for our undergraduate and graduate programs and (2) as part of the accreditation process, to enable the candidate to document field experience hours in Pass-Port, and electronic portfolio system. Thank you for your cooperation.
Please check your role:
___Cooperating Teacher ___University Supervisor ___ Supervising Teacher of Student Teachers Name: Gender: Male Female
First Middle/Maiden Last
School:Parish/District: Current Teaching Assignment:
Grade Level(s) Subject(s)
School E-mail:_______________________________ Fluent in Multiple Languages: Yes No
American Indian or Alaskan Native Black, Non-Hispanic Hispanic
Asian or Pacific Islander Foreign/Non-Resident Alien Not Reported
White, Non- Hispanic
Please check all that apply:
State Certification National Board Certification Currently Seeking National Board Certification
Certification Type: If you are not sure, please check the Teach LA site (http://teachlouisiana.net)
1. Are you currently teaching/working in your area of certification? Yes No
2. Highest Degree Earned: Bachelor’s Master’s Master’s +30 Specialist Ph.D. or Ed.D.
3. Total Years Teaching:______(Minimum of 3 years required) Total Years at this site:_____________. 4. How often do you incorporate the use of technology into your teaching and learning activities?
Daily Weekly Monthly
5. How often do your students use technology in learning activities?
Daily Weekly Monthly
6. How often do you develop and teach lessons that incorporate diversity (ethnic, racial, gender, and socioeconomic
Daily Weekly Monthly Yearly
7. Do you meet the qualifications to serve as a Supervisor of Student Teaching? Yes No
8. Are you one of the following? If so, please circle.
Hammond, Louisiana 70402 Field-Based Experiences Classroom Information (FBECI)*
NOTE: A copy of this form will remain in the field classroom in order to accommodate
other field candidates.
Teacher’s Name: _______________________________________________________________
First Middle Last
Breakdown of participants: Please indicate a numerical value for each. Total Number of Students: _____________ Males: ___________ Females: _____________
Total Number of Students with Exceptionalities: ______________
Exceptionalities: Indicate the number of candidates in the class with any of these exceptionalities.