Practicum Verification Form Special Education Program ‘Old Dominion University {In licu of the traditional 45 hour field-based practicum requirement, this student will complete the associated ‘assignments of the ODU special education practicum course within his/her current teaching placement. Student’s Name: Wloan Rodos t SSN/UID: WZ11D44 Distance Leaming site FOS Gox Nile Schoo! SPED Course #:_ SEED GOS, Oh, wn WEL | verify that the above student currently is teaching students with the following identified disabilities: (please check the appropriate categories) ___ Students with intellectual disabilities 7 Students with learning disabiti Students with emotional disabilities “2 Students with autism spectrum disorder _— Students in early childhood special education = Students with developmental delays __— Students with multiple (severe) disabilities Signature of mentor/administrator/department chair SYUo- -0 *Contact phone number of mentor/administrator/department chair lofto/20a> Date = The Special Education Program at Old Dominion University reserves the right to verify practicum placement with mentor/administrator/department chair (clinical faculty). Revised 6/11Practicum Hours Sign-In Sheet Special Education Program Old Dominion University Student name: S ers aye Se Distance learning site attended: Se “ Student numberump:_O)\2 |) NUL SPED course: SOE\D USS School name: DIA Doco nen oieitfsradetevet: (9 Supervising teacher’s (clinical faculty) name: WOada Noole *Contact phone number for supervising teacher: 010 ~ 800 - OBS, Date ‘Time in Time out ‘Teacher's signature Hours L_- 21-22] 7:30 2 Bd 1 9-20-24] 1:30 2.30 I [9-27-24] 1:30 2:30 T 9-2¥-22| 13d 2:30 7 103-22 | 130 2:30 71 10-4 -22 | 1:30 23d qd 10-5-2% | 1:40 ID: 4O 3 ours: |_45 University reserves the right to verify practicum * The Special Education Program at Old Domi hours with supervising teachers (clinical faculty). Revised 6/1104 Dominion Unversity Darden Celene of Eaecaton ‘racic Evslertion Teaber Candie MOYO Recap sss Coarse Nomber__ 3A HO Semestertvear_ FON “2O2Z ___ vndergrndunte Graduate Licemrre Only uinasy LZ O44 Cinta realy WOO Nabi ome (0 saree English Assigned Schoo! Ditriet_ SP OAC OOO soo Poss Dox, Nice, Meer Completes: 18s otter teechone "ete vat thither end he ais her pti for aching Be om prermone yar tron ving th taming le: An Baceede Expectations 3~Mects Expectations 2% Needs Improvement I= Unceeptable 0» Not Oberved oe a erie [_Frafetional Demesaor Dresses professes, ‘cogs seedeled wih nial helt (Soperatng tach) ands potoal nds prompily aed profesinaly te sks Tees = ra | = z = x Deeestrates Knomfege and lia mor etary = TE Atertmral eed Feedback Provides feedback to student a aly Bane = Tit stpdeas a evalentng ei ove performance res Hac See X ws the following sete ‘Se Allor nearly allt the stedents 4=Many ofthe studeats About balff the students 2=Few ofthe tndeats I=Nooeorslmest none of tbe sodeot, ps Srsdcor Wagon Testracton z= a Siostur of aia PaceinSepervier Onn Aa Af Wreofle tm_Zo Jy 202 opts to Fraestor, Cie! Fucaty,Canciate, ana Teacher Eacavon Services We arg yO having cher Un mir chosato! 7 Revised 6/11