Houston Baptist University

College of Education
Educational Diagnostician Practicum Agreement
I understand that I am participating in a practicum sponsored by the College of Education at Houston
Baptist University and the _________________________________
School District. I recognize that
St. Mark's Episcopal School
during the practicum, I am subject to the rules, regulations, and policies of the university as well as those
of the school district and campus.
I understand that during the practicum, I will be representing the university and the department and I will
not exhibit any behaviors that would adversely affect the image of either unit. I agree that if my behavior
is deemed improper or detrimental to the school district, campus, or the university, I will withdraw from
the program and not receive credit. I understand that failure to abide by the required guidelines of the
internship program will result in termination.
I further agree that I will: (a) avoid becoming involved in ideological disputes; (b) maintain the
confidentiality of records and internal matters at all times; (c) not be in possession of or use an illegal
controlled substance, alcohol, or firearm while on school or university property; and (d) always dress
professionally in accordance with school district policies.
I have read this agreement. The nature, scope, and required guidelines of the educational diagnostician
practicum have been explained to me, and I agree to abide by them.
Candidate:

Allie (Kathryn) Johnson

Name: _____________________________________________
(print)
Signature: __________________________________________
University Supervisor:
Name: ____________________________________________
(print)
Dr. Diane Reed
Signature: _________________________________________

EDSP 6315 Practicum in Diagnosis Syllabus Spring 2015

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Houston Baptist University

College of Education
Cooperating Site Administrator
Educational Diagnostician Practicum Agreement

Allie (Kathryn) Johnson

Candidates Name: _________________________________________________
Director of Technology
Position: ______________________________________________________
District: _______________________________________________________
Episcopal Diocese

St. Mark's Episcopal School

School: _______________________________________________________
As the Cooperating Site Administrator, I will support the above named individual during his/her
participation in the educational diagnostician practicum at Houston Baptist University. I understand this
program will require the candidate to perform assigned educational diagnostician duties during the regular
school day. I will provide the assistance and opportunities necessary to fulfill the requirements of the
practicum

Garhett Wagers
Name: ___________________________________________________(print)
Signature: _____________________________________________________

Return Form To:

University Supervisor

EDSP 6315 Practicum in Diagnosis Syllabus Spring 2015

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Houston Baptist University

College of Education
Cooperating Site Educational Diagnostician
Educational Diagnostician Practicum Agreement

NO Diag on Campus
Candidates Name: _________________________________________________
Position: ______________________________________________________
District: _______________________________________________________
School: _______________________________________________________

As the Cooperating Site Educational Diagnostician, I will support the above named individual during
his/her participation in the educational diagnostician practicum at Houston Baptist University. I
understand this program will require the candidate to perform assigned educational diagnostician duties
during the regular school day. I will provide the assistance and opportunities necessary to fulfill the
requirements of the practicum.

Name: ___________________________________________________(print)

Signature: _____________________________________________________

Return Form To:

University supervisor

EDSP 6315 Practicum in Diagnosis Syllabus Spring 2015

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Cooperating Site Educational Diagnostician Evaluation of Candidate

No Diag on campus
Candidate: __________________________________________________________________
Cooperating Site Educational Diagnostician: ________________________________________
Please use the chart below in evaluating the performance of the candidate who has been an intern on your campus by
placing an X in the appropriate column. Upon completion of this evaluation form, please return to the university
supervisor.
Please rate the candidate on the following criteria:
Above
Average

Average

Below
Average

Did Not
Observe

Cooperation
Ability to Organize/Perform Assignments
Problem Analysis
Decisiveness
Ability to Use Supervision
Personal Motivation
Judgment
Written Communication
Oral Communication
Sensitivity
Ability to Relate to School Staff
Stress Tolerance
Ability to Relate to Students
Educational Values
Range of Interests
Overall Performance
Ability to Assume Educational Diagnostician
Assignments
Additional Comments:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Signature of Cooperating Site Educational Diagnostician

Date

Please return this form to:

University Supervisor- (Place in a sealed envelope with your signature and give to the intern.)

EDSP 6315 Practicum in Diagnosis Syllabus Spring 2015

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