Click to print this page. Click to Return to previous page.


Questions in bold face throughout the questionnaire are for Non-native Speakers of English only.
1. Where were you born? __________________________________________________________
2. (If not born in U.S.) How old were you when you came to the USA? ____________________
3. What was the first language you spoke as a child? __________________________________
3a. (If other than English) Do you still speak this language?    yes / no
4. What is the highest school grade you completed not including adult education? __________
4a. Why did you leave school?______________________________________________________
5. In what town or city, state (country) was that school?_______________________________
6. (If not born in the U.S.) Did you attend school in (native country)?    yes / no
7. (If yes to #8) How many years? __________________________________________________
8. (If yes to #8) In what language were you taught? ___________________________________
9. Can you read (native language)?   yes / no
10. Can you write (native language)?   yes / no
11. Can you read and write English?   yes / no / a little
11a. How old were you when you learned to read and write English? ________________
12. Where did you learn to read and write English? (home, school)?________________
13. How many schools did you attend as a child? ______________________________________
14. Did you ever repeat a grade? yes / no. (If yes) Which grade(s)? ______________________
15. Do you remember ever having trouble with reading as a child     yes / no
16. (If yes) In which grade did you first have trouble? ____first grade; ____ second or third grades; ____ fourth or fifth grades; ____ sixth, seventh or eighth grades; ____high school
17. When you were a child did you ever participate in any of the following programs; if you did, please describe when and where.
___Individual Tutoring____________________________________at home______in school______
___Chapter I or Title I ____________________________________________________________
___Resource Room_______________________________________________________________
___Special Classes________________________________________________________________
___Core Evaluation_______________________________________________________________
___Special education_____________________________________________________________
18. What made you decide to take adult education classes?_____________________________
19. What do you plan to do after you complete your adult education classes?_______________
20. About how many hours a week do you read for pleasure (in English)? ___less than 1;
___1-3; ___4-6; ___more than 6
21. About how many hours a week do you read for pleasure in (native language)?
___less than 1; ___1-3; ___4-6; ___more than 6
22. What do you find hard about reading? Which of the following problems seem to apply to you when you read?
  Native Language
I can't read or pronounce the long, hard words. ___
I can't understand most of the hard words. ___
Sometimes I don't understand what I read. ___
I forget a lot of what I read right afterwards. ___
I forget a lot of what I read a few days later. ___
I read very slowly. ___
Other problems?________________________ ___
Spelling problems? ___
Click to print this page. Click to Return to previous page.