This form should be completed by candidates who are completing clinical assignments (prior to the yearlong internship placement) more than 50 miles from the University, in their own classroom as a lateral entry or resident candidate, or were pre-assigned through the course instructor. This form should not be completed for candidates whose choice of clinical placement is unavailable in our clinical database.  Prior to completion of this form, candidates should ensure the district/school is not listed in the online clinical sign-up. Students seeking placements in a local school or district, should not reach out to schools for a placement. Districts/schools listed in the online clinical portal should not be captured using this form. This form can also be utilized for candidates completing clinical hours in their own classroom (Resident, Graduate Teacher of Record or a Teacher Assistant without a confirmed placement).