Please fill this sheet out in its entirety.

You will be required to complete this in an electronic format in LiveText and submit this hardcopy to the Office of Clinical Experiences or your instructor. See your instructor for clarification if needed.

Spadoni College of Education – Coastal Carolina University Field Experience Diversity Data Collection Sheet
Field Experience II (Jr. I) Field Experience III (Jr. II) MAT Fall Methods Your Name CCU ID Course Name/Number for Field Experience Name of Instructor Date(s) of Visit(s) by Instructor Name of School for Field Experience Name of School Principal School Address Name of Classroom Teacher Classroom Teacher E-mail Classroom Teacher’s Signature Grade Level Placement Field Experience Beginning Date Subject(s) Field Experience Ending Date Male Female Program Area Male Female Field Experience IV (Sr. I)

***For the remainder of this form, if your placement serves more than one class, choose your most typical class and only report on that class.*** Type of Classroom Experience (check all that apply)
General Education_____ Resource Room_____ Collaboration (General & Special)_____ Other (Specify)__________________________________

Experiences with Special Needs (check all that apply)
Gifted/ Talented____ Speech____ Special Education____ Occupational Therapy____ English Language Learners____ Other (Specify)_____________ None_____

Classroom Diversity Enter Number of Students in Each Classification
____Total Enrollment in Class ____Black or African-American ____White ____Hispanic or Latino (of any race) ____American Indian/Alaskan Native ____Asian ____Native Hawaiian and other Pacific Islander ____Some other race ____Two or more races

Cooperating Teacher Diversity
____Black or African-American ____White ____Hispanic or Latino (of any race) ____American Indian/Alaskan Native ____Asian ____Native Hawaiian and other Pacific Islander ____Some other race ____Two or more races

Free/Reduced Student Lunch Percentage: Racial Minority:
Revised 05/17/10 J. Dix

Greater than or equal to 60% Greater than or equal to 40%

Less than 60% Less than 40%