The University of Nebraska at Omaha is an equal opportunity educator and employer with a comprehensive plan for diversity.
15-Hour Renewal Application
Personal Information Initial Meeting Date:
Name_____________________________________________ NUID___________________________
Street Address _____________________________________________________________________
City___________________________________ State______________ Zip______________________
Phone______________________(office, home, cell) Email __________________________________
Certificate Information
Date of Initial Certificate_______________________ State___________ Expiration Date___________
Recommending Institution for Initial Certificate_____________________________________________
Other States in which you have been certified______________________________________________
Have you ever had a certificate revoked/denied? □ No □ Yes
Employment History
Most recent employer______________________________________ Dates_____________________
Contracted Teaching Experience-School District(s)__________________________________________
Date(s)__________________ Teaching Responsibilities_____________________________________
Other_____________________________________________________________________________
Future Plans
Future Employment Plans
_________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Plans for Meeting the 15-Hour Renewal Requirements
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Personal and Professional Fitness Information Signed □ No □ Yes
Other Information
__________________________________________________________________________________
__________________________________________________________________________________
LiveText must be purchased for use in courses. Please contact Dr. Becky Pasco at rpasco@unomaha.edu
for more information.
The University of Nebraska at Omaha is an equal opportunity educator and employer with a comprehensive plan for diversity.
100-Hour Practicum Application
Personal Information
Name NUID
Street
Address
City State Zip
Phone (office, home, cell) Email
Term Practicum is requested □ Fall □ Spring
(year)
Major(s) ____ ECI Elementary Secondary / PK-12 Special Education
Endorsement Area(s)
100- Hour Practicum Options (Please check one-either Classroom Placement ,Substitute or InService )
Classroom Placement*
: The practicum student should register for TED 8980-801
(100-Hr Practicum) for
3
credit hours. The practicum will be arranged through the Practicum
Coordinator. A schedule will be set that meets the needs of the practicum candidate and is
acceptable to the district, school administrator and cooperating teacher of the hosting school. It
is recommended that the practicum student observe the cooperating teacher for a short period
of time (one or two days) and then become actively involved in the classroom. Planning,
assisting, teaching and assessing are appropriate activities for the one-hundred-hour practicum.
A journal of the practicum experience is required.**
District Requested School Requested
Grade Level Requested_ If grades 7-12, Content Area Requested
*
A background check must be completed prior to enrollment and issuance of a permit for TED 8980. Please
email Ms. Lorraine Street at lstree[email protected]
for more information.
If your practicum placement will
be in a school district where you are currently employed or a substitute teacher, a background check
is not required.
Substitute or InService Teaching
: If the practicum student has a valid substitute certificate and previous
contracted teaching experience, the practicum may be accomplished in the role of a substitute teacher. The
practicum student should register for TED 8980-801 – Practicum (100 Hour Practicum) for 3 credit hours. One-
hundred clock hours of substitute or inservice teaching must be documented and verified by the district/school
during the semester in which the candidate registers for the practicum. A journal of the substitute or inservice
teaching experience is required.
(LiveText must be purchased
The University of Nebraska at Omaha is an equal opportunity educator and employer with a comprehensive plan for diversity.
**The journal of the practicum experience (classroom placement, substitute or
inservice teaching experience) must be recorded and submitted to the Practicum
Coordinator in Roskens Hall 204 by
December 1 in the fall semester
and
May 1
in the spring semester
. The journal should provide:
•
A brief summary of the practicum setting
•
A brief daily account of the observation/teaching activities in which the
candidate has participated
•
The signature of the practicum candidate
•
The signatures of the cooperating teacher and/or administrator of the school
in which the practicum has been completed
In Case of Accident or Emergency
Next of Kin Relationship
_______________________________
Whom do we notify in case of an accident?
_______________________________________
Address
Home Phone_____________________ Business/Cell Phone
__________/____________
Student Signature_________________________________ Date
____________________
Please print, complete and submit this form to:
Practicum Coordinator
Office of Academic Advising and Field Experience,
College of Education University of Nebraska at Omaha
Roskens Hall, 204
6001 Dodge Street
Omaha, NE 68182
The application should be submitted prior to the semester in which the practicum is
to be completed and prior to registration for the practicum. Placements for the
practicum are arranged shortly after the beginning of the semester in which the
practicum is to be completed. The Coordinator will be in contact with the practicum
student to make these arrangements. If you have any question, please contact the
Practicum Coordinator at 402.554.4916
The University of Nebraska at Omaha is an equal opportunity educator and employer with a comprehensive plan for diversity.
CRIMINAL CHARGES SELF-REPORTING FORM
This form must be completed if you answered “YES” to Question #4 on the
Personal and Professional Fitness Form.
Name:
Please print
NUID#:
Complete a separate section for each charge. Document additional charges on reverse side of this form.
Return this form to the College of Education’s Office of Student Services, Roskens Hall 204.
Court documents related to each charge must be furnished.
Student Signature (do not use pencil) Date
.
5/5/14
Office of Student Services, Roskens Hall 204
Charge #1
Criminal charge:
Date of offense: County in which offense occurred:
Name of arresting party/agency (Police or Sheriff’s Office):
Court of Jurisdiction:
Plea and conditions of probation, if any:
Details of the incident (you may attach a separate sheet for further explanation):
Charge #2
Criminal charge:
Date of offense: County in which offense occurred:
Name of arresting party/agency (Police or Sheriff’s Office):
Court of Jurisdiction:
Plea and conditions of probation, if any:
Details of the incident (you may attach a separate sheet for further explanation):
The University of Nebraska at Omaha is an equal opportunity educator and employer with a comprehensive plan for diversity.
PERSONAL AND PROFESSIONAL
FITNESS FORM
Name of Student ID Number
1. Have you ever had a professional license, certificate, permit, credential, or other document authorizing the practice of a
profession suspended, revoked, voided, denied, rejected, or voluntarily surrendered? Yes No
If yes, attach a written statement that fully explains the facts and where this occurred.
2. Are you currently the subject of any inquiry of investigation by any law enforcement agency, prosecutor’s office, governmental
body, or licensing agency? Yes No
If yes, attach a written statement that fully explains the facts and where this is occurring.
3. Is any action currently pending against you by any law enforcement agency, prosecutor’s office, governmental body, or licensing
agency? Yes No
If yes, attach a written statement that fully explains the facts and where this is occurring.
4.
Have you ever been found guilty of a felony or misdemeanor or entered a plea of guilty or no contest to a felony or
misdemeanor in any criminal, drug, or juvenile court? Yes No
*The ONLY exceptions are speeding and parking violations.
If yes, complete Criminal Charges Self-Reporting Form and provide court papers to the Office of Student Services.
5. Is an order or determination currently in effect by a court or any other governmental body which finds you be any of the
following: a mentally ill and dangerous person; mentally incompetent to stand trial; acquitted of criminal charges because of
insanity; an incapacitated person in need of a guardian; or unable to manage your property due to mental illness, mental
deficiency, chronic use of drugs or chronic intoxication? Yes No
If yes, attach a copy of the order and a written statement that fully explains the facts and where this occurred.
6. Are you currently an inpatient or resident in a mental health facility due to a determination by a qualified mental health
professional? Yes No
If yes, attach a written statement that fully explains the facts and where this is occurring.
7. Do you have a Social Security number? Yes No
If no, make an appointment to see the Certification Officer in the College of
Education’s
Office of Student Services, Roskens Hall 204, 402-554-3482.
If the status to any of the above questions changes while you are a student at UNO, you must complete a new form.
* If you answered “yes” to any of the questions, make an appointment with the Office of Student Services, Roskens Hall
204,
402-554-3482, immediately, if you have not yet discussed prior conviction(s). If you are in a graduate program and
have already received your teaching certificate, there is no need to contact the Office of Student Services if the
incident happened prior to your original teaching certificate was issued and is on record with the Nebraska
Department of Education.
Rev. 7/2014
I declare that the information furnished herein is true, correct, and complete to the best of my knowledge. I hereby grant th
e permission and
authorize the University
of Nebraska-Omaha (UNO) to verify all responses with any mental health facility or governmental agency and to obtain
and review all records maintained by any criminal justice agency, including a criminal history record information check, rega
rding any of my
criminal charges or convictions. I hereby release, discharge, and exonerate UNO, its employees, and any person so furnishing
information from
any and all liability of every nature and kind arising out of the furnishing of such records and information. I understand that any material
** This digital signature verifies authentication of this
The University of Nebraska at Omaha is an equal opportunity educator and employer with a comprehensive plan for diversity.
University of Nebraska at Omaha
College of Education
Professional Dispositions Statement
Teaching is a profession that requires its potential candidates to be individuals of integrity. Prospective teachers
must be able to demonstrate that they are individuals of strong moral character who can make mature decisions
for themselves and for the students whom they will teach. Teachers are responsible for the education, safety,
and well-being of anyone in their charge. The University of Nebraska at Omaha College of Education prepares
future teachers who show a high degree of moral character and the ability to act responsibly inside and outside
the classroom. These individuals must be able to serve as representatives of the College and the University and
must demonstrate the personal and professional dispositions of the teaching profession.
Inappropriate behaviors on the part of the candidates, which in the College’s reasonable judgment, violate the
University’s Student Code of Conduct, establish a lack of integrity or moral/ethical character, or demonstrate
conduct or patterns of behavior inconsistent with the personal and professional dispositions expected in the
teaching profession, shall be sufficient grounds for 1) denial of admission to or enrollment in educator
preparation programs, 2) dismissal or removal from programs, courses, observations, field experiences,
practica, clinical practice, and similar field-based experiences, and 3) withholding institutional recommendation
for certification. Such behaviors could be evidenced within the University or PK-12 school environment, outside
the University or PK-12 school environment, and/or in an electronic or digital context. Displays or patterns of
behaviors may be established by any credible means including, but not limited to, the facts surrounding a record
of arrests or convictions or information obtained by the University directly from a school or district official.
Teacher candidates should note that the College of Education must provide a recommendation for certification
in order for a student to obtain his/her teaching certificate. Accordingly, inappropriate behaviors by candidates
could jeopardize not only their educational goals at UNO but also their professional goals including the ability to
become a certified teacher.
Candidates who exhibit inappropriate behaviors may be referred for a Conference of Concern to formally
identify the unsuitable behaviors, recommend corrective action(s), and determine the candidate’s suitability for
continuing in educator preparation. Candidates who have convictions outlines in the Nebraska Department of
Education’s Rule 20, Section 005.07A, will be allowed to continue in the educator preparation program or
referred for certification only through an appeal to the Commissioner or State Board of Education.
I swear/affirm that I have read and understand the Professional Dispositions Statement of the College of
Education.
Print Name
Signature
Date
9/2/15
