OPEN MODULAR UNIVERSITY

SANTA ANA UNIVERSITY CENTER

EVALUATION OF SCHOOL PRACTICE
CYCLE 01 - 2016

I. GENERALITIES:

Intern: _____________________________________________________
Teacher (male) Teacher (female):____________________________________________________________
Subject of practice:___________________________________________________________
In case of disorder:_______________________________________________________________
Día:_________________________________________________ Hora:____________________

II. OBJETIVO: Valorar el desempeño docente del estudiante en la Practica Escolar.

III. INDICATION: Please mark with an “X” the column that quantitatively reflects the quality.
of the performance of the intern.

No CRITERIA VALUATION
10 9 8 7 6 5 4 3 2 1
1 Attendance to the practice
2 Punctuality in attending the practice
3 Personal presentation
4 Vocabulary used in their performance
5 Communication with tutor
6 Accept suggestions
7 Properly plan the assigned contents
8 Prepare teaching materials
9 While developing the therapy, it adheres to what was planned.
10 Use an appropriate methodology
11 Reflects initiative and dynamism in its development
12 Achieve maintaining the attention of students in psychotherapy
13 Show empathy during psychopedagogical therapy.
14 Carry out reinforcement activities during psychotherapy
He is creative (she is creative)
15
Subtotal of evaluations
TOTAL POINTS
AVERAGE GRADE

OBSERVATIONS:________________________________________________________________
________________________________________________________________________________

f. _____________________
Professor
F.___________________________ F.____________________
Tutor teacher Director
 FORM No 1
FOR USE OF
REGULAR CLASS

STUDENT REFERRAL FORM TO THE EDUCATIONAL THERAPY CLASS

SCHOOL NAME:___________________________________________________
ADDRESS:_______________________________________________________________
EDUCATIONAL DISTRICT:______________________________________________________
DEPARTMENT DATE:____________________________________________________

GENERAL DATA
NOMBRE DEL ALUMNO:____________________________________ SEXO:___________
EDAD:______________ AÑOS, MESES:____________ GRADO:_______ SECCION:_____

PROBLEMS REFERRED TO THE STUDENT.

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________
DATE OF TRANSMISSION: ______________________________________________________
NAME OF THE TEACHER REFERRED TO:
__________________________________________________________________________

SIGNATURE:________________________________
 FORM No 2
SERVICES OF
THERAPY.

READING - WRITING TESTS

LEVEL OBTAINED IN THE TEST.

Mechanical Reading:__________________________________________________________
Comprehension Reading:_______________________________________________________
Writing: _________________________________________________________________

OTHER TEST.

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________

EVALUATION

What results did you obtain:_______________________________________________________

_______________________________________________________
Perception: _______________________________________________________
Conceptualization: ________________________________________________________
Memory: ________________________________________________________
Execution: ________________________________________________________
Reading: _______________________________________________________
Writing: _______________________________________________________
Total: _______________________________________________________

_________________________________________________
Name of the Teacher.
 FORMULARY No. 3
SERVICE OF
THERAPY
EDUCATIONAL

INTERVIEW WITH PARENTS OR GUARDIANS OF THE CHILD

GENERAL DATA

STUDENT NAME: _____________________________________________________

DATE OF BIRTH: ____________________________________________________
GRADO:_____________ SECCION: _____________ REPEAT GRADE: ___________
ADDRESS OF RESIDENCE: ___________________________________________________
NOMBRE DEL PADRE: ______________________________________________________
NOMBRE DE LA MADRE:_____________________________________________________
IN CHARGE:______________________________________________________________

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________

__________________________________________
NAME OF THE INTERN

SIGNATURE: ____________________________________
 FORM No. 4
SERVICE OF
THERAPY
EDUCATIONAL
Descriptive diagnosis of the problem presented by the child:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________

TREATMENT PLAN:

NOMBRE DEL NIÑO (A): _____________________________________________________

GRADO: _____________

OBJECTIVE ACTIVITY

____________________________________
NAME OF THE INTERN
 FORM No. 6
CONTROL OF
INCOME AND EXPENSE
THERAPY CLASS
Educational

EDUCATIONAL CENTER:_______________________________________________________
TEACHER (O):______________________________________________________________
DIRECTOR:________________________________________________________________
DEPARTMENT:__________________________________________________________
DISTRITO:_________________________________________ FECHA:_________________

DATE INCOME LEVEL DATE LEVEL OF GRADUATION

DEGREE AND NOMBRE DEL MAESTRO

STUDENT'S FIRST AND LAST NAME AGE LEC MAT ESC LEC ESC MAT
SECTION REG. OR SCHOOL
No

OPEN MODULAR UNIVERSITY

SANTA ANA UNIVERSITY CENTER
SCHOOL PRACTICE ATTENDANCE CONTROL
CYCLE 01 - 2016
GRADE: LEVEL: SECTION: HIGH SCHOOL: YEAR SECTION:
TEACHER:
STUDENT (A) INTERN:
DAYS AND PRACTICE SCHEDULE:

Fecha:______________________
Entry time: ______________ Departure time:___________________
Practicing Firm: ______________ Tutor Firm (a):__________________

Fecha:______________________
Hora de entrada: ______________ Departure time:___________________
Practicing company: ______________ Tutor Firm (a):__________________

Fecha:______________________
Entry time: ______________ Departure time:___________________
Internship company:______________ Tutor Firm (a):__________________

Fecha:______________________
Entry time: ______________ Departure time:___________________
Intern firm:______________ Company Tutor (a):__________________

Fecha:______________________
Entry time: ______________ Departure time:___________________
Internship company:______________ Company Tutor (a):__________________

OBSERVATIONS:______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________