Practicum Hours Sign-In Sheet Special Education Program Old Dominion University Student name: Mocgocy od gece Distance learning site attended: {i WOK Student number/UID:_O12.1\ YL SPEDeourse#:_ {|S School name: _C}lod Dorney Univessijrage overs KO ‘Supervising teacher’s (clinical faculty) name: \V\\CQQE) Huleu *Contact phone number for supervising teacher: (570) $95 ~S/0/ * The Special Education Program at Old Dominion University reserves the right to verify practicum hours with supervising teachers (clinical faculty). Revised 6/11 Date Time in Time out Teacher’s signature Hours g/29l2e A_O0am 300 pm L o/30/2Z__| 2:00am 3 g Z q b Fl o/22 9.00000 3. D0gn bo 97122 A. Woam | 3: 0Dem lo Qis/22 O WO om 3. Wern Yu Quy (22 &. Wom Lorn S 7 GHG122 | Adam | ZOOM | LAA] 5 Total Hours: | HOPracticum Verification Form Special Education Program Old Dominion University In lieu 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:_|V oy 300 A gers SSN/UID: _OIZI| O44 Distance Leaming Site:_Livi Elemeac SPED Course #:_4 School: Dn WECSI I verify that the above student currently is teaching students with the following identified disabil check the appropriate categories) V Atudents with intellectual disabilities ‘Students with learning disabilities Students with emotional disabilities TZ Students with autism spectrum disorder ‘Students in early childhood special education —Z students with developmental delays ____ Students with multiple (severe) disabilities se aaa ‘Signature of mentor/administrator/department cbiair jes: (please S40) 39S -5/o/ *Contact phone number of mentor/administrator/department chair * 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(Old Dominion Univesity Daren Cate of Eascaton ‘rcces Estado . neces Noman Kocloers cour tember SPED 4 |S ‘SemesterrYear__F( Z. Poasergenduate Graduate iceasere Only vurvssn_() 21 i, u cream VCH OPL HOVE one KS see Zeucling (Math srt Sis oCac, som Lewinipied Sterne — Hours Completed: (checks one) - Pe nat chr etm hte er pot hn hnden puree er cram sg tn ring ah ‘> Exceeds Expectations 3~Mects Expectations 2=Needs Improvement 1= Unacceptable T_Protesieal Demeasor ‘Drees Alseeds foi aT aed ieee TE Knowledge of Rales and Procedares Reads aed complies wih eres of ss 3s a [Seaton Repos Tt Sends ie ee ms x ‘Stedent pose questions rested to sabject, sk ot materials belay wed Sia sf ad bere engin trot o strec on rene SCORE ‘Students repwod in W273 that indicate comprrheasi of materia Gamma Mig Cages has Scan We aby 1 OMeeaE Rar Taskich 1A Sea lessens. Tn per otgervatnn tine She uns able help Suppor a greap of Shldeby with ny Aisa ty cakyerts 1 an inks, Crvtanst Sh cy able fo Suggeeh Te staged Reucehyin Peele Ss nshecha tprrtle support % shaming sles egal ef Moshi Cebteg h conthn te ont heck Wise! guchas bebe wae | ker [een falening ta abe! lean * a es os ile ee - “cana of Copier Cat Fenty, Candas ad Fecher Pantin’ Revised 6/11 e