Education Administration

Transcription

1 INITIAL LICENSE PUBLISHED AUGUST 07

2 TABLE OF CONTENTS I. Introduction... 1 People to Know... 1 Mission Statement... 2 Course of Study Master s Degree... 3 Course of Study Certificate of Advanced Graduate Study... 3 II. Fieldwork Requirements... 4 A. Pre Practicum... 4 B. Practicum... 4 Standards for Practicum Placement... 4 Practicum Intent Form... 5 Description... 7 Suggested Activities for Practicum Students... 8 Professional Standards and Performance Assessment... 9 Supervising Practitioner Responsibilities College Supervisor Responsibilities Practicum Student Responsibilities Written Work Portfolio Requirements Grading Criteria Preservice Performance Assessment System III. Forms Supervising Practitioner Letter Midterm Evaluation Form Practicum Intervention Warning Preservice Performance Assessment (PPA) Things to Remember Practicum Report/PPA Practicum Report (Page 1 of the PPA) Time Record and Activity Report Evaluation of College Supervisor Evaluation of Preparation Program Student Evaluation of the Practicum Thank You List: Supervising Persons ii

3 I. INTRODUCTION The practicum is one of the most important experiences for students preparing to become administrators. This handbook is intended to provide much of the information needed to insure that the experience is mutually beneficial for the pre practicum and practicum student, the supervising practitioner, the cooperating school, and Springfield College. Section I of the booklet includes the introduction, people to know, the mission and course of study. Section II highlights general fieldwork requirements and describes expectations and requirements of the student teacher, the supervising practitioner and the college supervisor. The College is deeply grateful for the generous support and cooperation continually given by local school personnel. We will make every effort to continue and enhance these positive relationships by responding to suggestions and requests. Section III includes samples of all the forms used by the student, supervising practitioner, and college supervisors. Susan McCarthy Miller, Ed. D. Director of Master s Program in Administration Springfield College Locklin Hall, 305C Phone: e mail: Susan_McCarthy Miller@spfldcol.edu Robert Barkman, Ed. D. Chair, Education Department Springfield College Locklin Hall, 308 Phone: e mail: Rbarkman@spfldcol.edu Linda Davis Delano, Ph. D. Director, Educator Preparation & Licensure Springfield College Administration Building, Room 209 Phone: e mail: Ldelano@spfldcol.edu PEOPLE TO KNOW Page 1

4 EDUCATION DEPARTMENT MISSION STATEMENT The Springfield College Education Department is committed to preparing effective teachers for the 21 st century who will demonstrate critical thinking skills, knowledge of curriculum and reflective teaching practices. Our graduates will be prepared to create dynamic learning environments in which teaching and assessment meet the needs of all students. The department strives to strengthen partnerships with the community and foster teaching that empowers students, promotes equity, celebrates diversity and demonstrates a commitment to the Humanics philosophy. EDUCATION ADMINISTRATION PROGRAM MISSION STATEMENT Mindful of the importance of exceptional school leaders, the Program of Springfield College is committed to the preparation of effective, enthusiastic, and well prepared education administrators who will demonstrate a commitment to students and teachers and to the creation of responsive schools. The program highlights state standards, pertinent curricular issues, school law, and the attainment of heroic leadership skills for the 21 st century, as well as a commitment to the Humanics philosophy of Springfield College. The Springfield College Licensure Program was developed for individuals who already hold a Massachusetts teaching license and would like to enter the field of Administration. This site based Master s Degree or Certificate of Advanced Graduate Study (C.A.G.S.) program has been designed to accommodate teachers whose busy schedules make it difficult for them to continue their studies at the graduate level in a traditional degree program while meeting their professional teaching responsibilities. All courses in this program meet the requirements for Master s and advanced degrees at Springfield College and the Massachusetts Department of Education. Licensure is available for either Principal/Assistant Principal or Supervisor/Director, or both. Page 2

5 M.Ed. in EDUCATION ADMINISTRATION COURSE OF STUDY College Requirements: RSCH 610: Foundations & Methods of Research EDUC 626: Education Research Project 3 s.h. 2 s.h. Program Requirements: EDUC 607: Philosophical Foundations of Education EDUC 619: Contemporary Issues in Education EDUC 621: School Law EDUC 647: Legal Issues in Special Education EDUC 670: Group Process in Education EDUC 675: Culturally Responsive Curriculum Design & Implementation for Secondary Education OR EDUC 676: Culturally Responsive Curriculum Design & Implementation for ECED/ELEM Education EDUC 690: Role of the Principal/Assistant Principal OR EDUC 691: Role of the Supervisor/Director EDUC 694: Principles of Supervision 3 s.h. 3 s.h. 3 s.h. 3 s.h. 3 s.h. 3 s.h. 3 s.h. 3 s.h. EDUC 665: Administration Practicum Principal/Assistant Principal 6 s.h. OR EDUC 672: Administration Practicum Supervisor/Director This program leads to an initial license in the following areas: Assistant Principal/Principal (PreK 6, 5 8, 9 12) Supervisor/Director (All levels) Total = 35 Credits CERTIFICATE OF ADVANCED GRADUATE STUDY (C.A.G.S.) COURSE OF STUDY This program is designed for those who already hold a master s degree and teaching license. Students pursuing the Certificate of Advanced Graduate Study (C.A.G.S.) with anticipated licensure in Educational Administration must complete the courses listed above (or the equivalent). After a thorough transcript review, the student and advisor will determine an appropriate course of study. Six credits may be transferred into Springfield College from other graduate work, but no course may be used to satisfy more than one degree. A minimum of 32 s.h. of credit are required to earn the C.A.G.S. degree. Page 3

6 II. FIELDWORK REQUIREMENTS A. PRE PRACTICUM Description and Requirements: The pre practicum is defined as an early field based experience in a variety of educational settings, integrated into courses or seminars that address the Professional Standards for Administrators. These experiences may occur simultaneously with the practicum. The pre practicum in the Program is imbedded in the coursework and focuses on assignments dealing with administrators and visitations to a variety of schools and educational venues to assess effective leadership qualities. Students are frequently assigned Shadowing experiences where they will follow a principal or supervisor for a short period of time in order to assess administrative performance. B. PRACTICUM STANDARDS FOR PRACTICUM PLACEMENT Students presently enrolled in the Master s Degree or C.A.G.S. Program in administration will be eligible for practicum student status once the standards below have been met. 1. Completion of one year of course work in the program 2. Continuance of a minimum 3.00 cumulative grade point average for all courses taken 3. Scores of 70 or higher on the Communication and Literacy Skills Tests of the Massachusetts Tests for Educator Licensure (MTEL) 4. Demonstration of the personal characteristics needed to become an educator. (e.g. responsibility, dependability, perseverance, professionalism, and commitment to the field of education) 5. Recommendation for practicum placement by the appropriate department Once these standards have been met the student must fill out a Practicum Intent Form. A copy follows on the next page. The practicum setting is decided upon by the student, college, and cooperating system and all rules of the receiving school must be followed. See the Educator Preparation Handbook for more information on practicum policies and procedures. Page 4

7 Educator Preparation & Licensure Office Graduate Practicum Form 1. TYPE ALL ENTRIES. Be sure to complete both pages of the forms. 2. Get approval from the Program Director. 3. Return approved application to the Office of Educator Preparation & Licensure (Room 209 in the Administration Building, ). Name SS# DOB Permanent Address: Street City State Zip Phone# Home Phone Other Phone Major Education License you are seeking Practicum Site Semester School LEVEL Assistant Principal/Principal PK 6, 5 8, 9 12 Supervisor/Director All Practicum Dates Level Comments School Address City State Phone# School System Name of Supervising Practitioner Position/Role Total Number of years your supervising practitioner has been employed in this administrative position (can combine years in similar positions in other school systems, if applicable) Supervising practitioner s license number Field of Licensure Page 5

8 Standards for Practicum Placement Students enrolled in the Master s Degree or C.A.G. S. Program in administration will be eligible for practicum placement once the standards below have been met. 1. Completion of Springfield College Registration form. 2. Completion of one year of course work in the program. 3. Continuance of a minimum 3.00 cumulative grade point average for all courses taken. 4. Passing scores on the Communication & Literacy Skills Tests of the MTEL. 5. Demonstration of the personal characteristics needed to become an educator. (e.g. responsibility, dependability, perseverance, professionalism, and commitment to the field of education). 6. Recommendation for practicum placement by the Education Department. Further documentation needed in the Educator Preparation Office: 1. Evidence of three full years of employment in a school based or other educational setting. Massachusetts teaching license # 2. Copy of MTEL scores to Educator Preparation Office with this application MTEL Scores: Reading Writing Application approval: Program Director s Signature Date Page 6

9 DESCRIPTION Each student must successfully complete EDUC 665: Administration Practicum Principal/ Assistant Principal or EDUC 672: Administration Practicum Supervisor/Director. A practicum is a field based experience in the role and at the level of license sought and supervised jointly by the provider of an educator preparation program (college supervisor) and a supervising practitioner. Candidates are required to complete 300 clock hours in the field for licensure as a Principal/Assistant Principal or Supervisor/Director. The practicum is generally regarded as one of the most important experiences included in any administration preparation program. Although other requirements for licensure may vary from state to state, some form of supervised practicum is required by all. The main purpose of this supervised clinical experience is to provide as realistic a situation as possible for students and to make application of the theory and skills acquired during the earlier part of their program. A second purpose is to provide a practical means of assessment of the students ability to demonstrate minimum standards in the field of administration. Standards felt to be essential to the effective principal and director have been identified, and the student is required to demonstrate mastery of each prior to any endorsement for licensure. The students in the practicum experience will have the opportunity to work with administrators in the field. They will not only observe, but will also be involved in work with the community, curricular issues, including adaptation and choice of instructional materials; life skills curriculum needs; teaching methods; evaluation; and school mission and goals During the practicum experience, students will be required to: 1. complete a portfolio reflecting the specific duties of the practicum experience, including, a) preparation of budget b) interviewing staff c) scheduling d) evaluation e) assisting in closing or opening the school year f) updating school records g) planning and implementing staff development 2. keep a log of the 300 required hours and the specific duties and their relationship to the standards In an effort to assure the student of a successful and gratifying experience, it is necessary for the supervising practitioner, the student, and the college supervisor to work closely together throughout the assignment. The following information included provides background regarding our procedures and policies. Other information will be shared through conferences and meetings. Page 7

10 SUGGESTED ACTIVITIES FOR PRACTICUM STUDENTS The following activities and events present potentially valuable experiences for the intern. The mentor, intern and university supervisor should select those which fit into the intern s schedule and provide needed growth experiences. Some activities and events are more applicable to elementary, middle or high schools. 1. Preparing the budget 2. Administering the testing program 3. Staffing (screening, interviewing, selecting, placing, placing on probation, dismissing, nonrenewing) 4. Scheduling, planning the school calendar 5. Planning the in service program 6. Selecting textbooks 7. Preparing, evaluating, updating the plan of the school improvement plan 8. Evaluating personnel, professional and classified 9. Placing and grouping students 10. Organizing or reorganizing the parents group, volunteers, etc. 11. Updating faculty and student handbooks 12. Updating student and other school records 13. Planning and conducting staff development activities 14. Testing, enrolling, and placing students in preschool classes 15. Planning for summer school remedial, gifted 16. Scheduling maintenance and cleaning 17. Maintaining financial records and reports audits 18. Planning and conducting awards and recognition programs for students, personnel, parents, etc. 19. Planning and participating in graduation activities 20. Making committee assignments and arranging for representation of school on division committees 21. Assigning coaches and sponsors 22. Selecting grade level and departmental chairpersons Page 8

11 PROFESSIONAL STANDARDS FOR ADMINISTRATORS AND PERFORMANCE ASSESSMENT Students will do a practicum in the role and at the grade level for which they are seeking licensure. They will be judged on the basis of demonstrated ability to perform in the area of the specific license they are seeking. All evidence will be kept in an evidence binder and cited in the Preservice Performance Assessment for Administrators form. (a) Leadership 1. Articulates the purposes of education and the place of public schools in the United States of America 2. Articulates vision and mission. 3. Reviews, evaluates, and revises instructional programs on the basis of sound information and relevant data. 4. Knows and encourages appropriate uses of instructional technologies. 5. Promotes activities that honor academic excellence. 6. Involves staff in preparing and implementing professional development plans that are related to improved student learning. 7. Helps staff align their curriculum with the state s curriculum frameworks. 8. Understands principles of mentoring and provides new teachers with mentors. 9. Encourages experimentation and rigorous evaluation of new pedagogical approaches. 10. Plans effectively for the implementation of policy decisions, taking into account unanticipated consequences and costs. Assessment: Members of the Education Department will supervise students in the program in administration. There will be frequent visits that will include pre and post conferences with the administrative aspirants, as well as the supervisor and supervising practitioner. Students will complete a portfolio and journal that will reflect the completion of the state department standards and knowledge of Leadership. (b) Administration 1. Has effective oral and written communication skills. 2. Uses effective methods of personnel selection, supervision, and evaluation. 3. Practices relevant fiscal management policies and procedures. 4. Uses technology appropriately for his or her professional position. 5. Acts with integrity, fairness, and professionalism. 6. Understands plant facilities and equipment management. Assessment: Students in the program in administration will be supervised by members of the Education Department. There will be frequent visits that will include pre and postconferences with the administrative aspirants, as well as the supervisor and supervising practitioner. Students will complete a portfolio and journal that will reflect the completion of the state department standards and knowledge of Administration. (c) Equity Page 9

12 1. Assures presence and quality of educational programs that address the needs, interest, and abilities of all students. 2. Provides programs or activities that help all students acquire a positive civic identity and see themselves as integral members of our civic communities. 3. Fosters understanding that effort is a key factor in achievement. 4. Helps all students see themselves as a unique individuals responsible for their own actions. 5. Assures high academic expectations for all students. 6. Holds teachers, students, and self to high standards of performance and behavior. Assessment: Students in the program in administration will be supervised by members of the Education Department. There will be frequent visits that will include pre and postconferences with the administrative aspirants, as well as the supervisor and supervising practitioner. Students will complete a portfolio and journal that will reflect the completion of the state department standards and knowledge of Equity. (d) Community Relationships 1. Involves families and other community members in developing the vision, goals, improvement plans and programs for the school/district. 2. Promotes partnership among staff, families, the business community, and other community resources to enhance instruction. Assessment: Students in the program in administration will be supervised by members of the Education Department. There will be frequent visits that will include pre and postconferences with the administrative aspirants, as well as the supervisor and supervising practitioner. Students will complete a portfolio and journal that will reflect the completion of the state department standards and knowledge of Community Relationships. (e) Professional Responsibilities 1. Meets his or her legal and moral responsibilities. 2. Maintains interest in current developments in the professional discipline. 3. Knows educational principles and research that promote sound practices. 4. Studies educational research of relevance to professional responsibilities. 5. Is familiar with the range of instructional programs and policies that can promote academic learning for all students. 6. Is familiar with the range of students support services. 7. Is familiar with the range of professional training programs and providers for prospective teachers. 8. Knows multiple strategies to assess students performance. 9. Understands approaches to organizational change, school based management, and school restructuring. 10. Understands federal, state, and municipal laws and regulations affecting schools, staff and students, including laws on disability, civil rights, and responsibilities issues of liabilities, and requirements of due process. 11. Demonstrates understanding of current issues in American education. Page 10

13 Assessment: Members of the Education Department will supervise students in the program in administration. There will be frequent visits that will include pre and post conferences with the administrative aspirants, as well as the supervisor and supervising practitioner. Students will complete a portfolio and journal that will reflect the completion of the state department standards and knowledge of Professional Responsibilities. SUPERVISING PRACTITIONER RESPONSIBILITIES The supervising practitioner must hold or be specifically exempt from holding an appropriate license/certificate. In order to waive this requirement, a Supervising Practitioner Waiver Form must be completed and the waiver must be approved by the Educator Preparation Council and the Director of Educator Preparation & Licensure. Waivers are kept in student files. The supervising practitioner is expected to work closely with the student in achieving mastery of the Professional Standards and communicate with the college supervisor to assess progress or opportunities for improvement. The supervising practitioner will be asked to complete a midterm evaluation and review all of the evidence listed by the student on the final Preservice Performance Assessment (PPA), checking the student s evidence binder for supporting documents and collaborating with the college supervisor to verify, add and/or subtract evidence from the PPA. See the Springfield College Preservice Performance Assessment (PPA) System for more information. COLLEGE SUPERVISOR RESPONSIBILITES The college supervisor must visit the student a minimum of three times and work with the student and supervising practitioner to assess the progress of the student and make recommendations for areas of improvement. Unlike standard observation and evaluation of a student teacher, the assessment of an administrative aspirant requires attention to the behavior and performance of the student in administrative situations and the student s ability to achieve mastery of the Professional Standards. For example, a student might be observed in the following ways: 1) Student is assigned as principal for the day because of administrative absence. The college supervisor observes the interactions with teachers, students, parents, and staff evaluates the student s performance. 2) Student facilitates faculty meeting and prepares appropriate activities. The college supervisor attends the meeting and evaluates the student s performance. 3) Student organizes and runs a disciplinary meeting with parents, student, teachers, and other appropriate personnel. The college supervisor attends the meeting and evaluates the student s performance. 4) Student obtains permission from teacher to undertake a performance evaluation, completes a pre and post observation conference with the teacher, observes class, and writes final report. The program supervisor attends any of the conferences and evaluates the student s performance. Page 11

14 Although these are just some of the many examples, see the Suggested Activities for Seminar Experiences list for further ideas and ways in which an administration student might be supervised. Because of the unique nature of the each administration practicum, it is essential that the supervisors have previous experience in the specific role and level that the candidate is seeking licensure. Among other things, this enables the supervisor to familiarize the candidate with the school culture. The college supervisor will be asked to complete a midterm evaluation and final Preservice Performance Assessment (PPA) based on the Professional Standards for Administrators, checking the student s evidence binder for supporting documents and consulting with the supervising practitioner to verify, add and/or subtract evidence from the PPA. Work with the supervising practitioner to fill in a rating, write comments for each standard and complete the Summary Comments. See the Springfield College Preservice Performance Assessment (PPA) System for more information. PRACTICUM STUDENT RESPONSIBILITES Practicum students are expected to conduct themselves in a responsible and professional manner, realizing that they represent themselves, the college, the school, and the entire profession. They are expected to adhere to rules and regulations of the school and to arrange for a conference if problems arise. Most important, students are expected to maintain confidentiality, as administrative aspirants are exposed to extremely personal material concerning students, parents, teachers, and the community at large. Their interactions with the police and other law officials should be carried out with professionalism and discretion. Written Work and Portfolio Requirements: During the practicum experience of 300 hours, students are required to keep a detailed journal in which hours and corresponding state standards are recorded. They will also keep an evidence binder and build a comprehensive portfolio which may include their administrative work in the following: Newsletters, Memos Letters of congratulations, reprimand, etc. Parent communications Self assessment Proposals for school projects Teacher evaluations Publications Grading Criteria: The program supervisor/supervising practitioner will grade students based on: Three formal evaluations Written midterm evaluation and final Preservice Performance Assessment (PPA), based on the professional standards Administration portfolio Practicum journal Page 12

15 What follows is the suggested Preservice Performance Assessment (PPA) System. Springfield College Preservice Performance Assessment (PPA) System 1. Student Administrator puts all documents in an evidence binder. Lists appropriate documents in the evidence column of the Preservice Performance Assessment. All documents must be cited as specifically as possible (e.g., newsletter, meeting notes, teacher evaluations). 2. Student Administrator submits electronic copy of the draft Preservice Performance Assessment (PPA), with the evidence column filled in, to the College Supervisor at the midterm and provides a paper copy to the Supervising Practitioner. 3. College Supervisor, Supervising Practitioner, Student Administrator use the draft PPA to independently fill out the Springfield College Midterm Evaluation Form. 4. A 3 way midterm meeting is held to review student administrator progress. If satisfactory progress is not being made a Springfield College Intervention Warning form is to be completed. 5. Student Administrator submits an electronic copy of the final draft of the Preservice Performance Assessment (PPA), with the evidence column filled in, to the College Supervisor and Supervising Practitioner 3 5 days prior to the final 3 way final evaluation meeting. 6. Both supervisors review PPA and verify evidence. They can check the student s evidence binder for supporting documents. The supervisors then work together to assign ratings, write comments for each standard and the Summary Comments (p.6 of PPA). This is often done via e mail. Once both supervisors agree on all ratings and comments they meet with the Student Counselor for the final 3 way conference and then sign off on all pages of the PPA. Note: Samples of all of the documents referenced above can be found in this handbook. Page 13

16 III. FORMS SUPERVISING PRACTITIONER LETTER Dear Supervising Practitioner: Thank you for assuming responsibility for one of our practicum students this term. We hope that this assignment will be mutually beneficial. Our practicum students are expected to be sensitive to the school, to you, the faculty and to the school program. We are proud of the preparation and have urged them to become as involved as possible in all aspects of administration at their site. I anticipate seeing each student four times during the course of the practicum, (including the introduction and goals meeting). A follow up conference with you and the student will be held after each visit. I encourage you to request additional conferences if you feel the need to do so, or to notify me at school or home, should the need arise. Again, thank you for taking the time to mentor one of our students in the field of administration. It is important work for the future of education. If I can be of further assistance to you, please do not hesitate to contact me at Sincerely yours, Susan McCarthy Miller, Ed.D. Director, Ed. Admin. Master s Program Springfield College Page 14

17 SPRINGFIELD COLLEGE MIDTERM EVALUATION FOR ADMINISTRATION PRACTICUM Student's Name School Grade Level Date This evaluation form is to be completed independently at the middle of the practicum by the student, college supervisor and supervising practitioner. The student s draft PPA should be used to fill out this form. The results of these evaluations should be discussed in a three way meeting at the midterm.... STANDARD A: LEADERSHIP Strengths (Evidence is clear) Areas in need of improvement (Lack of evidence) Overall Rating of this Standard: 1 = Does not meet Standard 2 = Meets standard 3 = Exceeds Standard STANDARD B: ADMINISTRATION Strengths (Evidence is clear) Areas in need of improvement (Lack of evidence) Overall Rating of this Standard: 1 = Does not meet Standard 2 = Meets Standard 3 = Exceeds Standard Page 15

18 Springfield College Midterm Evaluation Form Page 2 Student: Date: / / STANDARD C: EQUITY Strengths (Evidence is clear) Areas in need of improvement (Lack of evidence) Overall Rating of this Standard: 1 = Does not meet Standard 2 = Meets Standard 3 = Exceeds Standard STANDARD D: COMMUNITY RELATIONSHIPS Strengths (Evidence is clear) Areas in need of improvement (Lack of evidence) Overall Rating of this Standard: 1 = Does not meet Standard 2 = Meets Standard 3 = Exceeds Standard STANDARD E: PROFESSIONAL RESPONSIBILITIES Strengths (Evidence is clear) Areas in need of improvement (Lack of evidence) Overall Rating of this Standard: 1 = Does not meet Standard 2 = Meets Standard Recommended Midterm Grade : 3 = Exceeds Standard Signature of Individual Completing Form: Date: Page 16

19 Springfield College Educator Preparation & Licensure Office Practicum/Practicum Equivalent Intervention Warning You are currently not making satisfactory progress in meeting your practicum requirements and standards. Students who fail to meet practicum requirements are at risk of failing and will not be recommended for licensure. Date Student Supervising Practitioner School Program/Grade Level College Supervisor City/State Area Needing Improvement (cite specific standards) Steps to be taken to make satisfactory progress College Supervisor Signature Supervising Practitioner Signature Date Date Date met with Director of Educator Preparation & Licensure Director s Signature I understand that if the above stated requirements are not met to the satisfaction of the college supervisor and the supervising practitioner upon the completion of the practicum, I will not be recommended for licensure. Student s Signature Date Page 17

20 Candidates are to provide evidence documenting that all standards A E have been demonstrated. Supervisors are to rate the candidate and provide comments. [Note: The practicum report is page one of the PPA] Standard A Leadership Indicators 1. Articulates the purposes of education and the place of public schools in the United States of America. Evidence 2. Articulates vision and mission. 3. Reviews, evaluates, and revises instructional programs on the basis of sound information and relevant data. 4. Knows and encourages appropriate uses of instructional technologies. 5. Promotes activities that honor academic excellence. 6. Involves staff in preparing and implementing professional development plans that are related to improved student learning. 7. Helps staff align their curriculum with the state s curriculum frameworks. 8. Understands principles of mentoring and provides new teachers with mentors. 9. Encourages experimentation and rigorous evaluation of new pedagogical approaches. 10. Plans effectively for the implementation of policy decisions, taking into account unanticipated consequences and costs. Rating: Explanation of Rating for Standard A Leadership Rating Scale: 1=Does Not Meet the Standard; 2=Meets the Standard, 3=Exceeds the Standard; NA=Not Applicable. Candidate s Name: License: College Supervisor (sign): Date: Supervising Practitioner (sign): Date: Page 18