University of Alabama at Birmingham



SCHOOL OF EDUCATION

SPECIAL EDUCATION PROGRAM

ACKNOWLEDGEMENT OF CERTIFICATION AREA & TEACHING SCHEDULE

(For Hired Interns)

____________________________________ is currently hired at my school, will be completing his/her internship as a hired

(Name of Teacher/Intern)

intern in the field of ____________________, will be providing special education services as prescribed in student IEPs, and

will be teaching the following courses during his/her internship:

|Course Title for each Course Taught |LEAPS Code for each |Grade Level of |# of Periods per Day Course will be Taught|If class is an inclusive class, what is |

|(as it appears in teacher’s official |Course |Course |Attach a copy of the teacher’s current |the general education teacher’s name? |

|schedule) | | |daily class schedule to this form (e.g., | |

| | | |Per. 1 – 10-10:55am English I, Per. 2 – | |

| | | |11-11:55am Journalism, etc.) | |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

| | | |How many class periods are in your | |

| | | |school’s daily schedule? | |

| | | |______________________ | |

I am aware that the ALSDE requires that special education student teachers have experiences providing special education services to children with disabilities from low and high incidence disability areas in order to receive Alabama Collaborative Teaching certification. For collaborative special education (K-6) programs, the internship shall include lower elementary (grades K-3) and upper elementary (grades 4-6) unless substantial field experiences were completed at both levels.

I am aware that the ALSDE requires that every intern teach (all day, every day, for 15 weeks) within his/her field of study and area of certification.

____________________________________________ ___________________________

Administrator Name (printed) Name of School

____________________________________________ ____________________

Administrator Signature Date

____________________________ ___________________________ _______________

Student Teacher Name (printed) Student Teacher Signature Date

REVISED: 05/22/12

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Please provide one copy of this form to the Office of Clinical Experiences

(dhedge@uab.edu; Fax: 205-975-5693) prior to the applicable student teaching term.

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