College of Education Office of Student Services KH 330 6001 Dodge Street Omaha, NE 68182-0161

FIELD PLACEMENT ADVISORY COMMITTEE
Student Appeal Form

Please complete necessary information on this form.
Then, follow the directions for submitting your appeal.

Date:

Name:    ID#:  

Phone with area code:

Address:

City:    State:    Zip:

I hereby certify that, to the best of my knowledge, the information submitted
for this appeal is accurate and complete.

______________________________________________________________
Signature                                                 Date

The Field Placement Advisory Committee is made up of the chairs of
departments/schools that offer undergraduate teacher preparation course work
and programs, the Coordinator of the College of Education Office of Student
Services, and the Coordinator of Field Placement experiences. The committee
acts as the appellate body for several types of student appeals in the college.
In filing an appeal, the student must complete, sign and submit this appeal form.

Type of Appeal: 

Out-of-Area Student Teaching Placement Request
Permission to take a course while student teaching
Permission to take a COE required course with a field experience
for a second time
Permission to enroll in a required COE course for a third time
Permission to participate in Intermediate Field Experience, practicum,
or student teaching after having been Withdrawn or failing the experience
Other (Please explain): _________________________________________________

Pertinent Academic Information

• Attach an Unofficial EBruno Transcript
• Current, cumulative GPA Total hours completed
• Date Admitted to Teacher Preparation:

Indicate your Department/School and programmatic area. (Check all that apply.)

Teacher Education (TED)

Elementary Education

Middle Level Education

Secondary Education

Special Education and Communication Disorders (SPED)

Health, Physical Education and Recreation

K-12 Physical Education
K-6 Physical Education
7-12 Physical Education
7-12 Health Education

College of Fine Arts

Art Education

Music Education

Nature of the Appeal

On additional sheets, state the reasons for your appeal and the resolution you are
seeking. Please provide sufficient detail and background information regarding the
nature of your appeal.

Plan of Study

Please include your projected long range plan of study for completing the remaining
coursework for graduation, certification, or endorsement. By semester, list courses
by department, number, and title (e.g., SPED 1400 Introduction to Communication
Disorders). Please use the attached form for completing your plan of study.
Click to download the Plan of Study Form (Microsoft Excel Spreadsheet)

Directions for submitting appeal:

1. Print the completed appeal form. (it does not submit electronically)
2. Sign and date the form.
3. Complete and print your plan of study.
4. Complete and print the information on the nature of your appeal.
5. Submit all materials to the following address:

   College of Education
   Office of Student Services KH 330
   6001 Dodge Street
   Omaha, NE 68182-0161

For Committee Use Only
Date of Review:	Decision:       ___ Granted ___ Denied
Comments: