Support Provider Information Form
THIS FORM IS TO BE COMPLETED BY THE PRINCIPAL OR DIRECTOR.  
Please assign the intern teacher a qualified Support Provider prior to their first day of teaching.  Qualifications of the Support Provider are listed in the form below.  The Support Provider role is to provide support and guidance to the intern during their intern placement. California Commission on Teacher Credentialing requirements state that interns must receive a minimum of 2 to 4 hours of support and guidance per week, and 95 hours per semester total, of which, 22.5 hours must be focused on developing their teaching of English Learner skills.  Interns may count hours of support and guidance received by meeting with or observing their Support Provider, Professional Development activities, support and guidance received through discussions and evaluations by the Principal, other faculty, meetings or workshops through the school or district.  Interns should meet with their Support Provider at least once per week.
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LAST NAME of the CSU Monterey Bay Intern *
First Name of the CSU Monterey Bay Intern *
Choose the CURRENT Semester *
LAST NAME of the Support Provider assigned to this intern *
First name of the Support Provider assigned to this intern *
This person is qualified to serve as a Support Provider because he/she meets all Commission on Teacher Credentialing requirements below: *
All three must apply to qualify as a Support Provider.
Required
Subject area the intern will be teaching: *
Title of the position the intern will be assuming: *
School Name: *
School District *
If you do not see your district listed, you must contact the Intern Coordinator, Chris Villanueva, to have an MOU sent for signatures prior to proceeding.
Full time/part time hours: *
Please enter the approximate hours per week the intern will be teaching.
I understand that as part of the collaborative process of choosing a district-employed supervisor, CSU Monterey Bay may disallow any assigned Support Provider due to a lack of qualifications, experience, or exemplary teaching skills. *
CTC requires that the assignment of a Support Provider be a collaborative process between the intern program and the employer.  As part of this collaboration, CSUMB reserves the right to disallow any assigned Support Provider for the reasons stated above.
I understand that the Support Provider will be meeting with the intern at least once per week to provide guidance and support.   *
I understand that the evaluative program assessment is separate from the employer’s evaluative assessment. *
Administrator: Please enter your first and last name below as a digital signature in agreement of the above statements. *
Email address of the Administrator completing this form:
Date:
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