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2023-2024 Intern Contact Log Form
Please log your hours and answer the following questions. Click to see the drop down list for each question.
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* Indicates required question
What is the issuance date on your intern credential?
*
(See front of your intern credential for issuance date.)
MM
/
DD
/
YYYY
Choose your program:
*
Choose
Multiple Subject
Single Subject
Mild/Moderate Support Needs(Special Education)
Extensive Support Needs (Special Education)
First Name
*
Your answer
Last Name
*
Your answer
Email Address
*
Your answer
Expiration date of your intern credential. Look up your credential at
www.ctc.ca.gov
*
(See front of your intern credential for expiration date.)
MM
/
DD
/
YYYY
Choose the category of activity you completed. More than one category may apply.
*
This form may be completed as often as necessary.
Development of knowledge and skills in the instruction of English Learners
Coaching, modeling, or demonstrating within the classroom
Assistance with course planning
Problem solving regarding students
Problem solving regarding curriculum
Development of effective teaching methodologies
Developing an IEP or IEPs
CSUMB Clinical Coach Supervision and Evaluation
Required
Number of non-English Learner hours logged during this activity
(72 needed per semester)
Choose
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
Number of English Learner hours logged during this activity
(23 needed per semester)
Choose
1
1.5
2
2.5
3
3.5
4
4.5
5
5.5
6
6.5
7
7.5
8
8.5
9
9.5
10
Choose the current month
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Choose
January
February
March
April
May
June
July
August
September
October
November
December
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