BATAAN PENINSULA STATE UNIVERSITY

BALANGA CAMPUS
BALANGA CAMPUS
Don Manuel
Don Manuel Banzon
Banzon Ave.,
Ave. Poblacion,
Poblacion (047) 613-5103
(047) 237-1480
City of
City of Balanga,
Balanga Bataan
Bataan www.bpsu.edu
www.bpsu.edu.ph
2100 Philippines
2100 Philippines
Email Address

COLLEGE OF EDUCATION

DAILY TIME RECORD

Name of Intern: ___________________________ Campus: ____________________

Program : ___________________________ Major: ______________________
Cooperating School: ________________________________________________________________

Signature of
DATE TIME Resource Teacher / TOTAL REMARKS
Cooperating HOURS
Teacher
IN OUT
August 19, 2019 7:30 5:00 8hours

Prepared by: Checked by:

_____________________ _______________________
Field Study / Student Teacher Resource Teacher / Cooperating Teacher

Our Vision Our Mission

A leading university in the Philippines recognized for its proactive To develop competitive graduates and empowered community members by providing
contribution to Sustainable Development through equitable and relevant, innovative and transformative knowledge, research, extension and production
inclusive programs and services by 2030. programs and services through progressive enhancement of its human resources
capabilities and institutional mechanism.
 BATAAN PENINSULA STATE UNIVERSITY
BALANGA CAMPUS
BALANGA CAMPUS
Don Manuel
Don Manuel Banzon
Banzon Ave.,
Ave. Poblacion,
Poblacion (047) 613-5103
(047) 237-1480
City of
City of Balanga,
Balanga Bataan
Bataan www.bpsu.edu
www.bpsu.edu.ph
2100 Philippines
2100 Philippines
Email Address

COLLEGE OF EDUCATION

STUDENT TEACHER’S WEEKLY TIME RECORD

Name of Intern: ___________________________ Campus: ____________________

Program : ___________________________ Major: ______________________
Cooperating School: ________________________________________________________________

DATE Non- Teaching Homework Total Signature of

(week) Teaching Activities and Planning Number of Cooperating
Activities Activities Hours Teacher
August 27-30 32

Prepared by:

__________________________
Student Teacher
Checked by: Noted by:

_______________________ _______________________
Cooperating Teacher Supervising Instructor

Our Vision Our Mission

A leading university in the Philippines recognized for its proactive To develop competitive graduates and empowered community members by providing
contribution to Sustainable Development through equitable and relevant, innovative and transformative knowledge, research, extension and production
inclusive programs and services by 2030. programs and services through progressive enhancement of its human resources
capabilities and institutional mechanism.
 BATAAN PENINSULA STATE UNIVERSITY
BALANGA CAMPUS
BALANGA CAMPUS
Don Manuel
Don Manuel Banzon
Banzon Ave.,
Ave. Poblacion,
Poblacion (047) 613-5103
(047) 237-1480
City of
City of Balanga,
Balanga Bataan
Bataan www.bpsu.edu
www.bpsu.edu.ph
2100 Philippines
2100 Philippines
Email Address

COLLEGE OF EDUCATION

COOPERATING TEACHER’S WEEKLY RESPONSE FORM

(This response form is designed to assist the cooperating teachers in giving specific
feedback. Please accomplish this form as objective as possible by putting a check on the
specific circle.)

PART A
Cooperating Teacher: School:
Student Teacher: Date (week):
Attendance Promptness Professional Appearance and Image
○ not attending at all ○ late all the time ○ appearance and image not suited
○ frequently absent ○ frequently late for the profession
○ rarely absent ○ generally punctual ○ appearance and image not
○ excellent attendance ○ always on time appropriate for the profession
○ appearance and image
appropriate for the profession
○ with exemplary appearance and
image as a teacher
Efficiency Sensitivity Independence
○ failed to accomplish the tasks ○ insensitive to other’s ○ dependent for others for ideas,
○ frequently accomplishing the opinions and emotions directions etc.
tasks late ○ limited sensitivity ○ perform tasks efficiently with little
○ accomplished the tasks as ○ sensitive to other’s opinions guidance and supervision
scheduled and emotions ○ perform tasks efficiently without
○ accomplished the tasks ahead ○ highly sensitive and supervision (independently)
of time diplomatic
Student Interaction Response to Criticism Collaboration and Collegiality
○ shy to interact with the ○ not open to criticism at all ○ prefers to work alone
students ○ welcome feedbacks but ○ shy to work with others
○ interact with students a little does not welcome change ○ prefer to be a part of team
○ easily interact with students ○ welcome feedbacks and ○ relates easily and works effectively
○ accepts responsibility for implement changes with the team
student learning ○ ask suggestions from others
constructively
Creativity Mastery of the Subject In general, how did she perform this
○ not creative in the delivery of Matter week as a student teacher?
her duties as a teacher ○ do not have mastery at all ○ Poor
○ need to improve more his/her ○ with minimal mastery of the ○ Fair
creativity subject matter ○ Good
○ artistic in the delivery of her ○ have a thorough grasp of ○ Excellent
duties as a teacher the subject matter
○ has a deep sense of artistry/ ○ very much knowledgeable
creativeness about the subject matter

Assessed by:

__________________________
(Signature over Printed Name of the Cooperating Teacher)

Our Vision Our Mission

A leading university in the Philippines recognized for its proactive To develop competitive graduates and empowered community members by providing
contribution to Sustainable Development through equitable and relevant, innovative and transformative knowledge, research, extension and production
inclusive programs and services by 2030. programs and services through progressive enhancement of its human resources
capabilities and institutional mechanism.
 BATAAN PENINSULA STATE UNIVERSITY
BALANGA CAMPUS
BALANGA CAMPUS
Don Manuel
Don Manuel Banzon
Banzon Ave.,
Ave. Poblacion,
Poblacion (047) 613-5103
(047) 237-1480
City of
City of Balanga,
Balanga Bataan
Bataan www.bpsu.edu
www.bpsu.edu.ph
2100 Philippines
2100 Philippines
Email Address

COLLEGE OF EDUCATION

COOPERATING TEACHER’S WEEKLY RESPONSE FORM

PART B
Please indicate at least three instructional power (specify with “ ̷ ” )that your student
teacher demonstrated in this week. At the same time, please identify at least three areas
(indicate with a “ + ” ) that the student teacher should focus on for the next week .
Areas Areas
STUDENT TEACHER’S PERSONALITY Instructional Management
1. neatness and grooming ○ 16. management of time ○
2. dynamism and enthusiasm ○ 17. management of the physical, ○
social and ○
psychological environment ○
3. voice modulation ○ 18. classroom routines ○
4. mannerisms and facial ○ 19. management of order and ○
expressions discipline of students
5. good rapport with the students ○ ○
Teaching Plans 20. classroom transitions ○
6. preparedness and neatness of ○ 21. reinforcing students’ behavior
plans
7. curriculum alignment of the ○ 22. reacting technique ○
plan
8. on time submission of plans ○ 23. management of instructional ○
materials
Classroom Instruction Assessment ○
9. punctuality ○ 24. use of various assessment tools
10. teaching methodologies ○ 25. checking and recording test scores ○
11. teaching strategies ○ 26. analyzing and interpreting test ○
results
12. teaching materials 28. fairness and ethical ○
considerations
13. questioning technique ○ 29. communication of test results
Content 30. providing feedbacks ○
14. in depth knowledge of the ○ If there are areas that need more
content attention, feel free to recommend
15. relate lessons to actual life ○ specific actions of how your student
situations teacher may strengthen these areas
16. update on the latest ○
development regarding content

Our Vision Our Mission

A leading university in the Philippines recognized for its proactive To develop competitive graduates and empowered community members by providing
contribution to Sustainable Development through equitable and relevant, innovative and transformative knowledge, research, extension and production
inclusive programs and services by 2030. programs and services through progressive enhancement of its human resources
capabilities and institutional mechanism.
 BATAAN PENINSULA STATE UNIVERSITY
BALANGA CAMPUS
BALANGA CAMPUS
Don Manuel
Don Manuel Banzon
Banzon Ave.,
Ave. Poblacion,
Poblacion (047) 613-5103
(047) 237-1480
City of
City of Balanga,
Balanga Bataan
Bataan www.bpsu.edu
www.bpsu.edu.ph
2100 Philippines
2100 Philippines
Email Address

COLLEGE OF EDUCATION

________________
(Date)

Dear Mr. / Ms. _________________,

Greetings of peace and prosperity!

The CHED Memorandum Order No. 30, series of 2004, as the legal foundations of the
experiential courses, requires our pre-service teachers to develop their teaching by
providing them with practical learning experiences in which they observe, verify, reflect on,
in actual school settings.

Along this line, all students enrolled in a student teaching program shall undergo
actual teaching outside the university campus for the semester _________, A.Y.
___________.

In view of this, we are requesting your permission to allow your son/daughter to

report to ________________________ (cooperating school) for this purpose. The inclusive
dates will be from ________ to ________. Please accomplish the form below with your
approval and return soonest.

Your support of our Student Teaching Program is highly anticipated. Thank you very
much!

Truly yours,

Noted:

LEANDRO T. OLUBIA, Ed. D.

Supervising Instructor

LOURDES S. SANTOS, Ed. D.

College Dean
_________________________________________________________________________________

PARENT’S CONSENT
I give permission for my son / daughter _______________________________ to
undergo her Student Teaching at __________________ from ____________ to ______________.

______________________________________
(Parent’s Signature over Printed Name)

_____________________
(Date Signed)

Our Vision Our Mission

A leading university in the Philippines recognized for its proactive To develop competitive graduates and empowered community members by providing
contribution to Sustainable Development through equitable and relevant, innovative and transformative knowledge, research, extension and production
inclusive programs and services by 2030. programs and services through progressive enhancement of its human resources
capabilities and institutional mechanism.
 BATAAN PENINSULA STATE UNIVERSITY
BALANGA CAMPUS
BALANGA CAMPUS
Don Manuel
Don Manuel Banzon
Banzon Ave.,
Ave. Poblacion,
Poblacion (047) 613-5103
(047) 237-1480
City of
City of Balanga,
Balanga Bataan
Bataan www.bpsu.edu
www.bpsu.edu.ph
2100 Philippines
2100 Philippines
Email Address

COLLEGE OF EDUCATION

EXCUSE SLIP FORM

Name of Student Teacher:

Major :
Cooperating School :
Name of Critic Teacher :

Date of Application :
Date(s) of Absence :

Please check the reason of absence:

o Illness
o Medical appointment
o Injury
o Seminar-trainings
o Family emergency
o Other reasons (Please indicate:
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________

(Note: Please attach to this form a copy of medical certificate, university memo and/or excuse letter)

This is to certify that the application of _______________________ to make his/her absence

be excused has been ( ) approved / ( ) denied by the undersigned.

LEANDRO T. OLUBIA, Ed. D. _________________

Supervising Instructor Date Signed

Our Vision Our Mission

A leading university in the Philippines recognized for its proactive To develop competitive graduates and empowered community members by providing
contribution to Sustainable Development through equitable and relevant, innovative and transformative knowledge, research, extension and production
inclusive programs and services by 2030. programs and services through progressive enhancement of its human resources
capabilities and institutional mechanism.
 BATAAN PENINSULA STATE UNIVERSITY
BALANGA CAMPUS
BALANGA CAMPUS
Don Manuel
Don Manuel Banzon
Banzon Ave.,
Ave. Poblacion,
Poblacion (047) 613-5103
(047) 237-1480
City of
City of Balanga,
Balanga Bataan
Bataan www.bpsu.edu
www.bpsu.edu.ph
2100 Philippines
2100 Philippines
Email Address

COLLEGE OF EDUCATION

_________________

To: Secondary School Principal

Department Head
Cooperating Teacher

Sir / Madam,

This letter is a request that _________________________, a Practice Teacher

assigned at _________________________________, be excused from his/her Student
Teaching Program on ___________________.

Attached is his/her request letter.

Thank you very much for your kind consideration!

Sincerely yours,

LEANDRO T. OLUBIA, Ed. D.

Supervising Instructor
Noted:

LOURDES S. SANTOS, Ed. D.

College Dean

Our Vision Our Mission

A leading university in the Philippines recognized for its proactive To develop competitive graduates and empowered community members by providing
contribution to Sustainable Development through equitable and relevant, innovative and transformative knowledge, research, extension and production
inclusive programs and services by 2030. programs and services through progressive enhancement of its human resources
capabilities and institutional mechanism.
 BATAAN PENINSULA STATE UNIVERSITY
BALANGA CAMPUS
BALANGA CAMPUS
Don Manuel
Don Manuel Banzon
Banzon Ave.,
Ave. Poblacion,
Poblacion (047) 613-5103
(047) 237-1480
City of
City of Balanga,
Balanga Bataan
Bataan www.bpsu.edu
www.bpsu.edu.ph
2100 Philippines
2100 Philippines
Email Address

COLLEGE OF EDUCATION
PHOTO
Field Study and Student Teacher’s Profile
I. Educational Background

Student Number : _______________________________________

Campus : _______________________________________
Program : _______________________________________
Major : _______________________________________
High School Graduated From: _______________________________________
School Address : _______________________________________
_______________________________________
For Second Courser and CTP
Degree Earned : _______________________________________
University/ College Graduated From: ____________________________________

II. Personal Background

Name of Intern : _______________________________________
Home Address : _______________________________________
_______________________________________
_______________________________________
Telephone Number : _______________________________________
Mobile Number (s) : _______________________________________
Age : ______________ Date of Birth: _____________
Sex : ______________ Civil Status : _____________
For Married, Spouse’ name : _______________________________________
Spouse’ occupation: ______________ Number of children: _______
Name of Father/Occupation: _______________________________________
Name of Mother/Occupation: _______________________________________
E-mail Address: _______________________________________

III. Medical Background

Blood Type : _______________________________________
Medical History (Please indicate the type of illness(es) that you have at present
or had)
________________________________________
________________________________________
________________________________________
Person to Notify in Case of Emergency : _____________________________
Relation : _____________________________
Complete Address : _______________________________________
_______________________________________
_______________________________________
Telephone Number : _______________________________________
Mobile Number (s) : _______________________________________

__________________________
(Signature over printed name of the intern)
Our Vision Our Mission
A leading university in the Philippines recognized for its proactive To develop competitive graduates and empowered community members by providing
contribution to Sustainable Development through equitable and relevant, innovative and transformative knowledge, research, extension and production
inclusive programs and services by 2030. programs and services through progressive enhancement of its human resources
capabilities and institutional mechanism.
 BATAAN PENINSULA STATE UNIVERSITY
BALANGA CAMPUS
BALANGA CAMPUS
Don Manuel
Don Manuel Banzon
Banzon Ave.,
Ave. Poblacion,
Poblacion (047) 613-5103
(047) 237-1480
City of
City of Balanga,
Balanga Bataan
Bataan www.bpsu.edu
www.bpsu.edu.ph
2100 Philippines
2100 Philippines
Email Address

COLLEGE OF EDUCATION

DEMERIT SLIP

Name of the Student:

Experiential Learning Course:
Cooperating School:

Misdemeanors:

TARDINESS

Intensity of Offense Date Reported: Student’s SI Signature

Signature

First Offense : Reprimand ______________ ________________ _______________

Date Signed: Date Signed:

Second Offense: Warning ______________ ________________ _______________

Date Signed: Date Signed:

Third Offense: Dropped ______________ ________________ _______________

Date Signed: Date Signed:

INAPPROPRIATE ATTIRE AND GROOMING

Intensity of Offense Date Reported: Student’s SI Signature

Signature

First Offense : Reprimand ______________ ________________ _______________

Date Signed: Date Signed:

Second Offense: Warning ______________ ________________ _______________

Date Signed: Date Signed:

Third Offense: Dropped ______________ ________________ _______________

Date Signed: Date Signed:

MISBEHAVIOR

Intensity of Offense Date Reported: Student’s SI Signature

Signature

First Offense : Reprimand ______________ ________________ _______________

Date Signed: Date Signed:

Second Offense: Warning ______________ ________________ _______________

Date Signed: Date Signed:

Third Offense: Dropped ______________ ________________ _______________

Date Signed: Date Signed:

Our Vision Our Mission

A leading university in the Philippines recognized for its proactive To develop competitive graduates and empowered community members by providing
contribution to Sustainable Development through equitable and relevant, innovative and transformative knowledge, research, extension and production
inclusive programs and services by 2030. programs and services through progressive enhancement of its human resources
capabilities and institutional mechanism.