Demographics Clinical Experiences Form - All Programs With Technology Survey 2025.2026

Demographics Clinical Experiences Form - All Programs With Technology Survey
ALL candidates must complete the biographical information at the beginning of this form.
Today's Date*

MonthDayYear
Candidate Name*

First NameLast Name
Candidate E-mail*
Candidate Gender*

FemaleMalePrefer to Not Answer
Candidate Ethnicity*

African AmericanAsian/Pacific IslanderCaucasianHispanicNative American/AlaskanOtherPrefer to Not Answer
Candidate Program*

Initial Teacher Licensure, Undergraduate, Elementary, K-5Initial Teacher Licensure, Undergraduate, Secondary, 6-12Intiial Teacher Licensure, Undergraduate, K-12Initial Teacher Licensure, Special EducationMaster of Education, Initial Teacher Licensure, Elementary, K-5Master of Education, Initial Teacher Licensure, Secondary, 6-12Master of Education, Initial Teacher Licensure, K-12Master of Education, Initial Teacher Licensure, Special EducationMaster of Education, Counseling and Guidance, School CounselingMaster of Education, Counseling and Guidance, Mental Health CounselingMaster of Education, Instructional PracticeMaster of Education, Educational LeadershipMaster of Education, Instructional LeadershipSpecialist in Education, Instructional PracticeSpecialist in Education, Educational LeadershipSpecialist in Education, Instructional LeadershipDoctorate in Education, Curriculum and InstructionDoctorate in Education, Instructional Leadership
Class Site*

Cedar Bluff, KnoxvilleChattanoogaHarrogateKingsportOnline
Course Number*
(example EDUC-340)
Semester*

FallSpringSummer
Year*

2022202320242025202620272028
Are you an International Student?

YesNo
District Level
District or Agency Name
Number of Students in District
Number of Teachers in District
Percentage of Male Students in District
Percentage of Female Students in District
Percentage of African American Students in District
Percentage of Asian/Pacific Islander Students in District
Percentage of Caucasian Students in District
Percentage of Hispanic Students in District
Percentage of Native American/Alaskan Students in District
Percentage of Other Race/Ethnicity Students in District
Percentage of Students with Disabilities in District
Percentage of Limited English Proficiency (or ELL) Students in District
Percentage of Economically Disadvantaged Students in District
Technology Available to Candidate at the District/Community Agency Level (Check All That Apply)

Active Response System (e.g., Activotes, Clickers, Plickr)Computer-Based Learning Software (e.g., Plate Learning System)Digital CamerasInteractive White Boards (e.g., SmartBoard, Promethean)Laptops/ComputersOnline Behavior Management System (e.g., Class Dojo)Online Learning Management (e.g., Blackboard, Edvance 360)Tablets / Mobile DevicesOther
School Level
School Level of Your Clinical Experiences

Elementary (K-5)Middle (6-8)High (9-12)Non-traditional (e.g., alternative, adult)
Name of School Where Clinical Experiences Occur
Address of School

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
School Category

RuralSuburbanUrban
Number of Students at School
Number of Teachers at School
Student:Teacher Ratio at School
Percentage of Males at School
Percentage of Females at School
Percentage of African American Students at School
Percentage of Asian/Pacific Islander Students at School
Percentage of Caucasian Students at School
Percentage of Hispanic Students at School
Percentage of Native American/Alaskan Students at School
Percentage of Other Race/Ethnicity Students at School
Percentage of Students on Free or Reduced Lunch at School
Percentage of Economically Disadvantaged Students at School
Technology Available to Candidate at the School Level (Check All That Apply)

Active Response System (e.g., Activotes, Clickers, Plickr)Computer-Based Learning Software (e.g., Plate Learning System)Digital CamerasInteractive White Boards (e.g., SmartBoard, Promethean)Laptops/ComputersOnline Behavior Management System (e.g., Class Dojo)Online Learning Management (e.g., Blackboard, Edvance 360)Tablets / Mobile DevicesOther
Classroom Level
Grade Level of Classroom
Number of Students in Classroom
Percentage of Male Students in Classroom
Percentage of Female Students in Classroom
Student:Teacher Ratio in Classroom
Percentage of African American Students in Classroom
Percentage of Asian/Pacific Islander Students in Classroom
Percentage of Caucasian Students in Classroom
Percentage of Hispanic Students in Classroom
Percentage of Native American/Alaskan Students in Classroom
Percentage of Other Race/Ethnicity Students in Classroom
Percentage of Students Receiving Special Education Services (e.g., 504, IEP, Gifted)
Technology Available to TEACHER in the Classroom (Check All That Apply)

Active Response System (e.g., Activotes, Clickers, Plickr)Computer-Based Learning Software (e.g., Plate Learning System)Digital CamerasInteractive White Boards (e.g., SmartBoard, Promethean)Laptops/ComputersOnline Behavior Management System (e.g., Class Dojo)Online Learning Management (e.g., Blackboard, Edvance 360)Tablets / Mobile DevicesOther
Technology Available to K-12 STUDENTS in the Classroom (Check All That Apply)

Active Response System (e.g., Activotes, Clickers, Plickr)Computer-Based Learning Software (e.g., Plate Learning System)Digital CamerasInteractive White Boards (e.g., SmartBoard, Promethean)Laptops/ComputersOnline Behavior Management System (e.g., Class Dojo)Online Learning Management (e.g., Blackboard, Edvance 360)Tablets / Mobile DevicesOther
You have now completed the Demographics Form for this Clinical Experience. Please click the SUBMIT button to record your answers.
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Demographics Clinical Experiences Form - All Programs With Technology Survey

District Level

School Level

Classroom Level