Criteria for Cooperating Teachers must

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Criteria for Cooperating Teachers
Cooperating teachers must

        1. Be approved by the school principal.

        2. Have a Louisiana Teaching Certificate.

        3. Have at least three years of teaching experience in his/her Louisiana certified area of teaching.

        4. 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

        5. Complete FORM B and keep it on site for candidate access.

Form A:CF

(Revised 8/13)

Southeastern Louisiana University

College of Education

Hammond, LA 70402

*This form is now online at

Field-Based Teacher Experience Questionnaire (FBTEQ)

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 (

Type A Practitioner Teacher

Type B Out of State Provisional Certification

Type C Out of Field Authorization to Teach

Level 1 Professional Certification Temporary Authority to Teach

Level 2 Professional Certification Temporary Employment Permit

Level 3 Professional Certification Ancillary Certification
Certification Areas: Please check all that apply.

Elementary Grades 1-8 Vocational Agriculture Mild/Moderate

Elementary Grades 1-6 Vocational Home Econ. Severe/Profound

Lower Elem. Grades 1-4 Family & Cons. Science Mentally Retarded

Upper Elem. Grades 5-8 Physical Education Learning Disabled

Kindergarten Health & Physical Ed. Academically Gifted

Nursery School  Driver/Traffic Safety Ed. School Librarian

Early Interventionist Aerospace Education Media Specialist

English French Guidance Counselor

Math Spanish Counselor in Elem./Sec. Schools

General Science Journalism Supervisor of Student Teaching

Biology Speech Reading Specialist

Chemistry Bus/Office Ed. Principal (K-12)

Physical Science Bus. Ed. Subjects Elementary School Principal

Social Studies Coop. Office Ed. Secondary School Principal

Instrumental Music Computer Literacy Parish/City School Sup. Of Instruction

Art Health Occupation School Superintendent

Early Childhood Education Grades Pk-3 Educational Technology Educational Leadership Level 1

Middle School Grades 4-8  English Second Language ESL  Educational Leadership Level 2


Name: ________________________________________

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.

 Technology facilitator  Resource Helping Teacher  Curriculum Coach/Instructor

List Professional Organization in which you are a member:


Supervising Teacher of Student Teachers: Submit to the assigned university supervisor working with you and your student teacher or intern.

All TEACHERS at METHODS sites should submit a completed form at the beginning of each academic year.

Field Experience Cooperating Teacher:

A. Complete Form A online or submit Form A to

the principal to be either:

a. emailed to or

b. mailed to: Dr. Heloise Aucoin, Director

Office of Field Experience

SLU 10671

Hammond, LA 70402

B. Form A must be submitted to the Office of

Field Experience before ANY candidate can

begin documenting field experience.

Qualifications to be a Cooperating teacher:

1. Recommended by the principal

2. Hold a LA teaching certification

3. At least three years of teaching experience.

4. Complete Form A and submit it to the

Office of Field Experience

5. Complete Form B to be kept in his/her class.

CLUs will be issued to each cooperating/

Supervising teacher at the end of the academic


Form B

(Revised 7/13)

Southeastern Louisiana University

College of Education

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.

_____Autism _____Deaf/Blind _____ ESL _____Developmental Delay

_____Gifted _____Hearing Impairment _____Emotional Disturbance

_____Infant and Toddlers with Disabilities _____Mental Disability

_____Other Health Impairment (may include ADD) _____Multiple Disabilities

_____Specific Learning Disability _____Orthopedic Impairment

_____Speech/Language Impairment _____Talented

_____Traumatic Brain Injury _____Visual Impairment

_____Temporary Disability (i.e., broken arm, broken leg, etc.) _____Limited Proficiency

Grade Levels: Select the grade(s) of the participants

_____Early Intervention (Birth to 3) _____Pre-K _____Kindergarten

_____1st _____2nd _____3rd _____4th

_____4.5 _____5th _____6th _____7th

_____8th _____8.5 _____9th _____10th

_____11th _____12th

Ethnicity: Please indicate the number of candidates for each ethnicity within the class.
_____American Indian or Alaskan Native _____Hispanic

_____Asian or Pacific Islander _____Not Reported

_____Black, Non-Hispanic _____White, Non- Hispanic

_____Foreign/Non-Resident Alien

Subject: Select the subject(s) taught.

_____Art/Music _____Mathematics _____Language Arts

_____Business _____Science

_____Foreign Language _____Social Studies _____Other:________

_____Health/PE _____Special Education __________________

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