Field Placement Evaulation Form - The University Of Tennessee At Chattanooga Page 2

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H
C
D
E
AMILTON
OUNTY
EPARTMENT OF
DUCATION
C
& I
D
URRICULUM
NSTRUCTION
EPARTMENT
3074 H
V
R
, C
, TN 37421
ICKORY
ALLEY
OAD
HATTANOOGA
423-209-8538
HCDE S
F
E
A
F
TUDENT
IELD
XPERIENCE
PPROVAL
ORM
Dear School Principal:
My name is __________________________________________ and I am a current student at ____________________. A requirement for course:
____________________________ (list course name & number) is that I:
 Observe in a ____________________________________ class for ____________ hours, starting on:
__________________________________ and ending on: __________________________________________________.
 Conduct a case/field study that involves (include number of hours required and start date):
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
_________________________________________
 Other (Please explain and list total number of hours required and start date):
______________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________
__________________________________________
I am willing to submit to a criminal background check in keeping with the guidelines of the Hamilton County Department of Education, if required to do so
and will do so prior to starting my approved field placement course requirement with HCDE. To the best of my knowledge, there is nothing in my
background that would prevent me from working as teacher in Tennessee public schools I further understand that HCDE will determine whether or not a
background check is required and HCDE will not incur the cost for the criminal background check.
_________________________________
_________________________________
________________
Signature of Student
Print Name of Student
Date
_________________________________
__________________________________
________________
Signature of Professor Witness
Print Name of Professor
Date
 Approved
 Not Approved
 Approved Pending Background Check
___________________________________
________________________________ ___________________________
School Principal Signature
School
Date
Students Are Required to Show Current College ID to Principals
This Form Is Not To Be Used for Student Teaching

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