TEACH= ING PERFORMANCE & CERTIFICATION= CENTER

KEA= N UNIVERSITY – COLLEGE OF EDUCATIO= N

WILLIS 110 – UNION, NJ 07083=

Phone: 908-737-4185/Fax: 908-737-4= 115

Email: tpc@kean.edu=

Request for Honorarium & Professional Development Ho= urs for Professional Intern Mentoring

To recei= ve an honorarium and certificate for New Jersey Professional Development Hours, please complete the information below and mail to the Teaching Performance Center<= /st1:PlaceType> or return it to the student’s university supervisor by October 1 for = the Fall semester, February 1 for the Spring semester. Honorarium requests received after June 30 (end of the current academic year) will not= be honored.

Directions: Darken the ovals completely - Like this:●.&nbs= p; Do not X or check √ the circle. All erasures must be complete.

Semester: <= /span>O Fall O <= /span>Spring O <= /span>Summer Year _______ &= nbsp; University Supervisor: ______________________________

O Mr. O Ms. = Last Name __________________________________ &nb= sp; First Name: _______________________________

Home Address: _______________________________________________________= _____________________________________

City, St Zip &nbs= p; _________________= ___________________________________________________________________________=

Telephone<= span style=3D'font-size:10.0pt'>: &nb= sp; ______________________= _________________ Your Social Security #: _________- ________-________

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; (Required for payment of honorarium)

Name of Kean Student: ______________________________________ = ; Your School District: _______________________________

Your School & Address: ___________________________________________________________________________= ____________

Is this a Professional Development School (PDS) with Kean University?: &nb= sp; O Yes O No

Will you share the mentoring responsibilities for this student with another teacher? O Yes O No

If yes, please indicate the teache= r(s) name(s): _= ___________________________________________________________________________= _

1. Age:&nb= sp; O 20 or below O 21-30 O 31-40 = O 41-50 &= nbsp; O 50+

2. Certifications (fill in as many as apply) &= nbsp; O P-3 &= nbsp; O K-8 O K-12 Subj= ect Area = O Teacher of Handicapped

3. &nbs= p; Are you a Kean graduate? O Yes O No If no, whe= re did you receive teacher training? ____________________________

4. &nbs= p; Degree (Fill in highest attained) O Bachelors= O Masters O Doctorate= =

&= nbsp; Decade Final Degree Obtained: O 196= 0 O 1970 = O 1980 = O 1990 = O 2000

5. &nbs= p; Ethnicity (Fill in one) O Asian &= nbsp; O Black &= nbsp; O Hispanic<= span style=3D'mso-tab-count:1'> &= nbsp; O Native American = ; O White

6. &nbs= p; Have you previously mentored/supervised university field experience students? O Yes= O No =

7. &nbs= p; If you answered Yes to # 7, How many students have you mentored?

&= nbsp; O 1-2 O 3-5&nb= sp; O 6-8 O 8-10 O 10+

8. &nbs= p; Were you assigned or did you volunteer to mentor this student? (Fill in only one) O Assigned &nb= sp; O Volunteered

9. &nbs= p; In your opinion, what are the most important factors in selecting a cooperating teacher? Please fill in up to= five (5).

&= nbsp; O Tenure (or equivalent) status &= nbsp; &nbs= p; &= nbsp; &nbs= p; O Pedagogic= al knowledge

&= nbsp; O Degrees (= beyond B.A.-M.A., Specialist, Ed.D.) &n= bsp; = ; O Interpers= onal skills

&= nbsp; O Classroom teaching experience and record &= nbsp; &nbs= p; = O Willingne= ss to serve (volunteer)

&= nbsp; O Previous experience working with student teachers&nb= sp; = &nb= sp; O Teaching = style

= <= /span>O Type of s= chool or geographical location &= nbsp; &nbs= p; &= nbsp; O Content knowledge

= <= /span>O Ability to demonstrate best practice

= <= /span>O Other (please specify) _____________________________________________________

10. Does your union contract include provisions relating to mentoring? O Yes O No O Do not kn= ow

= &nb= sp; = &nb= sp; = (Please complete other side…)

11. As a result of your experience as a cooperating teacher, have you acquired new knowledge and/or skills? = O Yes O No

12. If yes to #11, please indicate: = O Technolog= y O Standards= O <= span style=3D'font-size:9.0pt;mso-bidi-font-size:10.0pt;font-family:Arial;mso-bi= di-font-family: "Times New Roman"'> Instructio= nal Strategies O Alternate Assessment

= O Other (please list) ___________________________________________________________________________= __

13. Do professional development hours make mentoring more attractive? O Yes O No

14. Did you have preparation in mentoring? O Yes O No

15. If yes to #14, please indicate where you received preparation: &n= bsp;

&= nbsp; O School di= strict workshop O University Workshop = O Course O Cooperating Teacher Institute

16. If no to #14, are you interested in a course or workshop in mentoring? O Yes O No<= o:p>

17. Would you accept the assignment as a cooperating teacher if preparation was required? = O Yes O No

18. Which professional development areas listed below would assist you in mentoring future university interns?

= <= /span>O Conducting observations &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; O Conferenc= ing and coaching

= <= /span>O Giving wr= itten feedback = ; &n= bsp; = ; &n= bsp; = ; O Communica= ting (with supervisor & student)

= <= /span>O Modeling = exemplary teaching = ; &n= bsp; = ; &n= bsp; O Ass= essing and evaluating

= <= /span>O Remediati= ng low-performing interns &nb= sp; = &nb= sp; O Other ______________________________

19. How helpful were the following professional development activities in preparing= you for your role as a cooperating teacher?

= &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; &= nbsp; Very Helpful Somewhat Helpful Not Helpful = N/A

&= nbsp; a) Informal interactions with colleag= ues &= nbsp; &nbs= p; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; b) Reading= of field experience handbook = &nb= sp; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; c) Reading= of literature on supervision = &nb= sp; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; d) Graduat= e work in supervision = ; &n= bsp; = ; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; e) Supervi= sion workshop = ; &n= bsp; = ; &n= bsp; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; f) Video on supervisory techniques &nb= sp; = &nb= sp; = O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; g) Seminar= (s) with other cooperating teachers = O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; h) Confere= nce(s) with university supervisor = ; &n= bsp; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; i) O= ther: __________________________ &= nbsp; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

20. Which of the following mentoring techniques do you use as a cooperating teacher?=

= &nb= sp; = &nb= sp; = &nb= sp; = &nb= sp; Frequently= Sometimes<= span style=3D'mso-tab-count:1'> = Rarely = = Never

&= nbsp; a) General feedback (verbal) &= nbsp; &nbs= p; &= nbsp; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; b) Lesson = plan feedback (verbal) &= nbsp; &nbs= p; = O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; c) Lesson = plan feedback (written) &= nbsp; &nbs= p; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; d) Modeling instructional behaviors &n= bsp; = ; &n= bsp; = ; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; e) Co-teac= hing with student &= nbsp; &nbs= p; &= nbsp; &nbs= p; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; f) P= rovide opportunities for experimentation &nbs= p; &= nbsp; &nbs= p; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; g) Written Observation(s) by another teacher(s) &= nbsp; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; h) E-mail exchanges with field experience student&nbs= p; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

&= nbsp; i) Other: _____________________________ &n= bsp; O = &nb= sp; O = &nb= sp; O = &nb= sp; O

21. Do you see yourself as a teacher educator? O Yes O No

22. Do you think the cooperating teacher’s performance should be assessed? &n= bsp; O Yes O No<= o:p>

23. If yes to #22, by whom? = ; O University Students = ; O University Faculty = O Both=

Comments about your mentoring experience: _________________________________________________________________

________________________________________________________= ______________________________________________

__________________________= ___________________________________________________________________________= _

Thank you for your input. The information you have provided = will enable the Teaching Performance Center to better serve the cooperating teacher’s needs and provide direction= for the placement of our student teachers. All information will be kept confidential.

Please return this form to the address on other side or to the student’s university supervisor. Certificates for Professional Development Hours will be mailed by February 1 for the Fall semester, June 1 for the Spring semester = and July 1 for the Summer semester.