School of Education, Health and Human Behavior


Applications are due in School of Education, Health and Human Behavior Student Services Office (1st floor, Founders Hall, Room 1110) by
Friday, January 30, 2015

A. Please select from one of the options below (students must complete a SEPARATE application for each experience)

1. General Information

2. Will you be living on campus?

3. If yes, list campus address if different from above address:

4. School attended (include city and state)

5. CONFLICT OF INTEREST: Candidates are placed in schools for field experiences and student teaching within a 40 mile radius of the University; however, candidates may not be placed in schools in which they have a potential conflict of interest.  Conflicts to be avoided are schools in which the candidate has attended, has relatives employed or attending or has any other potential conflicts that may impact his or her placement at the school.  Please list any schools within a 40 mile radius of SIUE in which you may have a potential conflict of interest and the type of conflict. 

6. HARDSHIPS: Please list any schools/districts/areas within a 40 mile radius of SIUE that would pose a hardship and describe the type of hardship.  Hardships might be driving distance from your home, schools that do not have special accommodations to meet your needs, distance from daycare, etc.  School of Education, Health and Human Behavior Student Services Office cannot guarantee you will not be placed in any schools listed but we will work to best accommodate your needs within the program parameters in seeking a field placement.  Please take notice that School of Education, Health and Human Behavior Student Services Office will not make changes after placements are established. 


7. By submitting this application, I give consent for SIUE to share any educational records, background check information and drug screening information with school partners.

BACKGROUND CHECKS: All students must have a background check clear of all enumerated offenses on file in School of Education Student Services Office before a placement will be confirmed. Students needing information about the background check should visit

Should the information contained in the background check change, it is their obligation to inform School of Education, Health and Human Behavior Student Services Office. Changes in criminal history could impact future placements and/or eventual certification.


The edTPA is an Illinois teaching licensure requirement for all teacher candidates who graduate after September 1, 2015. As part of the edTPA, the teacher candidate must video his/her teaching performance and the impact this instruction has on student learning. Students’ images and their voices must be recorded and student work samples scanned as evidence that learning occurred. The handling and use of the recordings and the student work samples must be done in such a manner that students and their work remain confidential throughout the process.

Following are your responsibilities in this process:

I will use any student work samples, any audio recordings and/or any video recordings for the sole purpose of the preparation and submission for the edTPA assessment as directed by my instructors at SIUE. I will not use these work samples or recordings for any other purpose.

I will do whatever is reasonable to protect the confidentially of any student work samples, and audio recordings and/or any video recordings of the students that I collect as part of my field experience or student teaching experience. I will only use first names of the students and will avoid using the name of the school and/or district when identifying student work samples or making recordings.

I understand that any scanned student work samples, any audio recordings and any video recordings will ONLY be uploaded to secure servers at SIUE for the purpose of evaluating my teaching knowledge, skills, and dispositions. Also, I will promptly delete any and all of these student work sample images, audio recordings, and/or video recordings from any devices other than the secure servers at SIUE; this deletion will occur absolutely no later than 24 hours after the end of the semester in which the images or recordings were made.

Any questions regarding your placement may be directed to Lindsey Loyd at 650-2469 or e-mail