Diversity Experience Log Sheet

Diversity Experience Log Sheet
Candidate Name*

First NameLast Name
E-mail*
Program*
Semester*
Year*
School Name *
Mentor Name*
For each category, list the number of hours you spend in each of the areas of diversity and then a short description in the following blank.
Number of clinical experience hours in urban setting
Date(s)
Description of activity
Nurmber of clinical experience hours in rural setting
Date(s)
Description of activity
Number of clinical experience hours in Special Education/ELL setting
Date(s)
Desciption of activity
Number of clinical experience hours in low socio-economic background setting
Date(s)
Description of activity
Number of clinical experience hours in racially/ethnically diverse (minimum of 10%) setting
Date(s)
Description of activity
Should be Empty: