Career Switcher Level I Practicum Observation Form
Career Switcher Level I Practicum Observation Form
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Full Legal Name
Full Legal Name
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First
Middle
Last
Email
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Phone
Phone
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Address
Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Canada
Australia
Netherlands
France
Germany
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Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
Gabon
Gambia
Georgia
Ghana
Gibraltar
Greece
Grenada
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Level I Cohort
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What endorsement are you seeking?
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Requested school division:
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Accomack
Albemarle
Alexandria
Alleghany
Amelia
Amherst
Appomattox
Arlington
Augusta
Bath
Bedford
Bland
Botetourt
Bristol
Brunswick
Buchanan
Buckingham
Buena
Campbell
Campbell
Caroline
Carroll
Charles City
Charlotte
Charlottesville
Chesapeake
Chesterfield County
Clarke County
Colonial Beach
Colonial Heights
Covington
Craig County
Culpeper
Cumberland
Danville
Dickenson
Dinwiddie
Essex
Fairfax
Falls Church
Fauquier
Floyd
Fluvanna
Franklin
Frederick
Fredericksburg
Galax
Giles
Gloucester
Goochland
Grayson
Greene
Greensville
Halifax
Hampton
Hanover
Harrisonburg
Henrico
Henry
Highland
Hopewell
Isle of Wight
King George County
King and Queen County
King William
Lancaster
Lee County
Lexington
Loudoun
Louisa
Lunenburg
Lynchburg
Madison
Manassas
Martinsville
Matthews
Mecklenburg
Middlesex
Montgomery
Nelson
New Kent
Newport News
Norfolk
Northampton
Northumberland
Norton
Nottoway
Orange County
Page County
Patrick
Petersburg
Pittsylvania
Portsmouth
Powhatan
Poquoson
Prince Edwards
Prince George
Prince William
Pulaski
Radford
Rappahannock
Richmond County
Richmond City
Roanoke
Roanoke County
Rockbridge
Rockingham
Russell
Salem
Scott
Shenandoah
Smyth
Southampton
Spotsylvania
Stafford
Staunton
Suffolk
Surry
Sussex
Tazewell
Virginia Beach
Warren
Washington
Waynesboro
West Point
Westmoreland
Williamsburg-James City
Winchester
Wise
Wythe
York
Have you been offered full time employment by the school division in which you're requesting placement?
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Have you been offered full time employment by the school division in which you're requesting placement?
Yes
No
Do you have any special request? (School name, instructor name, grade level)
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Do you have any special request? (School name, instructor name, grade level)
Yes
No
(If yes, please provide details in the space provided)
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Please read and acknowledge each of the following:
All request must go through the school division human resources department.
I will not be placed during SOL testing.
My requested school division is not guaranteed.
I must request my practicum through the ODU Career Switcher program unless I choose to be placed in a private school.
The length of time to be placed will depend on the time of the year and the school division.
Once my practicum has been sent to a school division, it may take up to six weeks to be placed.
I will not be placed during the summer months.
I may have to meet additional requirements by the school division before I am placed.
Draw
or
Type
Clear
Full Name
I acknowledge and understand the above points.
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I acknowledge and understand the above points.
Agree and Submitt