California State University Sacramento



MILD/MODERATE ONLY or DUAL M/M (M/M and MULTIPLE SUBJECT)FIELDWORK APPLICATIONAny candidate seeking to complete fieldwork requirements in the program must submit this application with an up-to-date Program Planning Sheet signed by your academic program advisor. Please meet with your advisor to complete the form and then submit your completed fieldwork application by the appropriate deadline date shown below. In order for the Placement Coordinator place you at a school, your Certificate of Clearance must be current. Again, you must meet with your advisor ahead to complete the form and then submit your completed fieldwork packet to the Teaching Credential Branch office (Eureka 401) by the appropriate deadline date shown below. A complete application packet consists of the following: FORMCHECKBOX Student Teaching Clearance form (approved by Teaching Credential staff) FORMCHECKBOX Application FORMCHECKBOX Program Planning Sheet(available through your advisor and with his or her approval signature) FORMCHECKBOX Administrator’s Letter of Support (if requesting to teach in own classroom as an intern teacher)SPECIAL NOTE: If you are requesting an intern assignment in your current teaching placement, you will also need to attach a Letter of Support from your Administrator. (See Admin. Letter of Support Sheet.) Mild/Mod Program/Fieldwork Placement Handbook is available at . Any Questions, please contact the Mild to Mod Program Placement Coordinator, Dr. EunMi Cho at eunmicho@csus.edu. Registering Semester:Application Submission Deadline:Fallby March 1Springby October 14625015-873155DEADLINE:March 1 for FallOctober 1 for Spring00DEADLINE:March 1 for FallOctober 1 for SpringSTUDENT TEACHING CLEARANCE FORMComplete the following section first and submit to Eureka 401. It will take at least 3 working days for processing by a teaching credential staff before the clearance form returns to Eureka 401. Pick it up from the office and submit the application packet with this form.Name: Student ID: Address: Primary Number: City: Zip: Alternate Number: Email:_________________________________ @csus.eduAlternate Email:___________________________________ Semester: Fall 20_____ Spring 20______Select One (1) Only.Mild/Moderate: Multiple Subject: FORMCHECKBOX EDS 471 FORMCHECKBOX EDS 472* FORMCHECKBOX EDS 420A FORMCHECKBOX EDS 420B**Students are required to have completed their Subject Matter Competency Requirement by passing and submitting all three sections of CSET scores to Eureka 401, but F2020/Sp21 to coe-cred@csus.edu) usually PRIOR to student teaching (EDSP420B and EDSP472), but F2020/Sp2021 is exceptional. For Office Use OnlyCommentsSubject Matter Competency Requirement FORMCHECKBOX CSET FORMCHECKBOX Credential FORMCHECKBOX Waiver FORMCHECKBOX ECSECBESTDate passed:Certificate of Clearance (COC)Expires:TBDate read:Grades FORMCHECKBOX Cleared________________________________________________________ _____________________________Teaching Credential Staff Signature DateComments: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MILD/MODERATE ONLY OR DUAL (M/M + MS) FIELDWORK APPLICATION FORMName: FORMTEXT ?????Student ID: FORMTEXT ??? Address: FORMTEXT ?????Home or Work Phone: City: FORMTEXT ????? Zip: FORMTEXT ?????Cell Phone: CSUS Email: ________________________@csus.eduAlternate Email:Check one: FORMCHECKBOX To Be Placed by a Coordinator FORMCHECKBOX To be an Intern Teacher Request for Fieldwork (check ONE only): FORMCHECKBOX Fall FORMCHECKBOX Spring Year: FORMDROPDOWN No student will find his or her own placement. Fieldwork placements are made in collaboration with district administrators and the M/M Placement Coordinator. Students will need to write one preferred school district’s name and circle the preferred grade(s). SECTION A – Field Experience and Student TeachingMild/Moderate & Multiple Subject Fieldwork CoursesPreferred District/Scool/Teacher NamePreferred Grade Level FORMCHECKBOX EDS 420A Field Experience - Gen. Ed. (6 units) FORMCHECKBOX EDS 471 Field Experience - Mild/Mod (4 units)EDS 420A: K–3 4–6EDS 471: K–3 4–6 7–8 9-12 FORMCHECKBOX EDS 420B St. Tchg. - Multiple Subj. (8 units)K–3 4-6 FORMCHECKBOX EDS 472 St. Tchg.- Mild/Mod. (8 units) K–3 4-67–8 9-12 SECTION B – EDS 473 InternshipIf you are requesting to teach in your own classroom as an intern teacher, please fill in the following information and attach your Administrator’s Letter of Support:School District: FORMTEXT ????? School Name: FORMTEXT ?????School Address: FORMTEXT ?????Principal Name and Email Address: FORMTEXT ?????Support Provider Name and Email Address: FORMTEXT ?????District’s Contact Person Name, Email Address, Job Title: FORMTEXT ?????Administrator’s Letter of Support: Yes***************************************************************************************************************************************Student Signature: ________________________________________________________ Date: ____________Advisor’s Signature: _______________________________________________________ Date: ____________ADMINISTRATOR’S LETTER OF SUPPORT FOR CREDENTIAL CANDIDATES REQUESTING AN INTERN ASSIGNMENT IN THEIR CURRENT TEACHING CLASSROOM.Credential candidates who request an intern assignment so they can fulfill their student teaching requirement in their current teaching placement need to obtain a letter of support from their employer. This letter will accompany the intern teaching application and up-to-date academic program plan signed by the candidate’s faculty advisor. It is the candidate’s responsibility to ensure that the application packet is submitted by the submission deadline. Upon approval, interns must begin to submit their monthly intern calendar to Elizabeth Christian at THE ADMINISTRATOR'S LETTER SHOULD:Indicate your administrator’s support for your request and identify an on-site or district support provider and other elements of a support system available to you in your school and/or district per MOU between Sacramento State and the district;Indicate your administrator’s willingness to cooperate with a university supervisor in providing for a quality intern teaching experience, which meets the requirements of the University Program’s fieldwork component;Describe your on-the-job placement regarding class assignment, duties and schedules; andIndicate your administrator’s understanding that you may be required to spend 3 to 5 days away from your position in order to visit model programs if needed appropriate to your area of training; released time from your job may be necessary.Note to intern teaching in a segregated school: If a credential candidate is employed as an intern teacher at a segregated school site (school that only serves students with disabilities), the arrangement will need to be made with the school (or district) administrator and the placement coordinator to ensure that the candidate gets adequate experience and opportunities to demonstrate all competencies and standards identified by the CTC. This needs to be addressed in the candidate’s letter of support. Once your application packet is received in the Teaching Credential Branch office (Eureka 401), it will be forwarded to the Mild Moderate Placement Coordinator. ................
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