Teacher Standards and Practices Commission
465 Commercial St NE
Salem, OR 97301
Voice (503) 378-3586
Student Teaching Or Practicum Report – Form PA-1
Each student teacher, an intern, or a candidate for final practicum in personnel service and school administration shall file with the
Commission a registration form (PA-1). The candidate must answer the character questions on page 2 of this form and shall submit a
fingerprint card following TSPC instructions.
Type Of Experience
ENTER the term or semester: ENTER the year during which you will be placed:
ENTER the type of practicum experience: Please place an (X) in the box of the college or university you are attending
1. Student teaching for an initial teaching license Cascade College Pacific University
2. Final practicum for special education endorsement Concordia University Portland State University
3. Final practicum for licensure as a personnel specialist Corban College Southern Oregon University
4. Final practicum for licensure as a school administrator Eastern Oregon University University of Oregon
5. Practicum – other George Fox University University of Phoenix
Lewis & Clark College University of Portland
Linfield College Warner Pacific College
Marylhurst University Western Oregon University
Multnomah Bible College Willamette University
Northwest Christian College Other ______________
Oregon State University
Student Teacher Or Practicum Applicant
LAST NAME FIRST NAME MIDDLE
DATE OF BIRTH SEX SOCIAL SECURITY NUMBER E-MAIL ADDRESS
ADDRESS: CITY, STATE AND POSTAL CODE
Ethnic Status: (Optional-for statistical purposes only)
1. Which race or ethnicity best describes you?
American Indian and Alaska Native Asian Black or African American Hispanic/Latino Multiethnic
Native Hawaiian or Other Pacific Islander White Other
Check Level And Endorsements Being Completed
Early Childhood Elementary Middle Level High School
Administrator Health Education Physics
Agricultural Science & Technology Family & Consumer Sciences Professional Technical Education
Art Integrated Science Reading
Biology Japanese Russian
Chemistry Language Arts School Counselor
Drama Latin School Psychologist
Early Childhood Marketing Social Studies
Educational Media Math, Advanced Spanish
ESOL Math, Basic Speech
ESOL/Bilingual Multiple Subjects Technology Education
French Music Special Education
General Business Ed. Physical Education Early Intervention /Special Ed.
German PE, Adapted Hearing Impaired
(TSPC.0033 – 3/5/2010)
You must answer each question either "yes " or "no" whichever is true. Explain each "yes" answer in detail on a separate
sheet, which also must be signed and dated.
1. Have you ever left any educational or school-related employment, voluntarily or involuntarily, while the 1. _________
subject of an inquiry, review or investigation of alleged misconduct or alleged violation of professional
standards of conduct or when you had reason to believe such investigation was imminent?
2. Are you currently the subject of an inquiry, review or investigation for alleged misconduct or alleged 2. _________
violation of professional standards of conduct?
3. Have you ever failed to complete a contract for educational services in any educational or school-related 3. _________
position, or for any alleged misconduct or alleged violation of professional standards of conduct been
placed on leave by your employer or left such employment prior to the end of the contract term?
4. Have you ever had a professional certificate, credential or license (of any kind) revoked or suspended or 4. _________
have you been placed on probationary status for any alleged misconduct or alleged violation of
professional standards of conduct?
5. Have you ever been denied a professional license for which you applied or granted a professional license 5. _________
on a conditional or probationary basis for any alleged misconduct or alleged violation of professional
standards of conduct?
6. Have you ever surrendered a professional license of any kind before its expiration? 6. _________
7. Have you ever been disciplined by any public agency responsible for licensure of any kind, including but 7. _________
not limited to educational licensure?
8. Have you ever been convicted or been granted conditional discharge by any court for: (a) any felony; (b) 8. _________
misdemeanor; or (c) any major traffic violation, such as: driving under the influence of intoxicants or
drugs; reckless driving; fleeing from or attempting to elude a police officer; driving while your license was
suspended, revoked or used in violation of any license restriction; or failure to perform the duties of a
driver or witness at an accident?
9. Have you ever been arrested or cited for any offense listed in question (8) above which is still pending in 9. _________
10. Have you ever entered a plea of guilty or No Contest relative to any charge for an offense listed in 10. _________
11. Have you ever had any civil judgment or other court order entered against you resulting from abuse, 11. _________
assault, battery, harassment, intimidation, neglect, stalking, or other threatening behavior toward other
NOTES: 1. Any false statement knowingly made in this application is grounds for refusal to issue an Oregon
Educator license. If in doubt, disclose and explain rather than conceal. If you answer “no” to questions 8
through 11 based upon an “expungement”, order “setting aside” or “sealing” of a record of a conviction or
conditional discharge you must personally verify with the court directly involved that the expungement, setting
aside or sealing actually has taken place. An erroneous belief that a conviction has been expunged, set aside or
sealed, when in fact it has not, will be deemed a false statement.
2. If you answer “yes”, a certified true copy of the court records must accompany this application (if not
previously submitted to TSPC).
Signature and the Date
I hereby certify that the information submitted on or relating to this form is true and correct and grant the Commission
permission to check civil or criminal records to verify any statement made on this application. The Commission may deny or
revoke permission for student teaching or final practicum upon evidence that I knowingly made any false statements on this form.
I also grant the Commission permission to release any information related to these character questions to the institution
supervising my practicum, internship and/or student teaching.
Signature of the student teacher or practicum applicant Date
*This application must be signed and dated within the 120-day period prior to submission to TSPC.
(TSPC.0033 – 3/5/2010)