Teacher Data Form

Adult ESL Literacy Impact Study

Teacher Data Form (2008)

Program Name: Site:

Last Name: First Name:

Address: Apt #:

Zip code:

Phone #: (______) _______ ___________

Classes taught at this program: ___________________________________________________

Name of Class in Study: ___________________ Meeting Days: _________ Meeting Times: ________

Languages Spoken and Proficiency (excluding English)

1. ________________________	2. ________________________	3. _____________________
Speaking:	Speaking:	Speaking:
 Fluent	 Fluent	 Fluent
 Moderate	 Moderate	 Moderate
 Little	 Little	 Little
Reading:	Reading:	Reading:
 Fluent	 Fluent	 Fluent
 Moderate	 Moderate	 Moderate
 Little	 Little	 Little

Gender: M ______ F ______

Racial Background

 White

 Black or African American

 Asian

 Native Hawaiian or Other Pacific Islander

 American Indian or Alaska Native

Ethnicity

 Hispanic or Latino

 Not Hispanic or Latino

Employment status at this program

 Part-time

• Full-time

Education Level (check all that apply)

 High school diploma

 Associate's degree

 Bachelor's degree (Education)

 Bachelor's degree (Other)

 Master's degree (Education)

 Master's degree (Linguistics/TESL)

 Master's degree (Other)

 Education specialist's or professional diploma based on at least one year's work past master's degree

 Doctorate (specify area): ____________________________

 Professional degree (e.g., M.D., LL.B., J.D.)

Current Certification (check all that apply)

 ESL/TESL certificate

 Advanced professional certificate

 Regular or standard state certificate

 Certificate issued by a state after satisfying all requirements except the completion of a probationary period

 Certificate issued by a state that requires some additional coursework, student teaching, or passage of a test before regular certification can be obtained

 Certificate issued by a state to persons who must complete a certification program in order to continue teaching

 Certification by an accreditation body other than the state

 No certification

Teaching Experience (round to nearest whole year)

	Years of Experience
Adult ESOL (any level; include years also reported under Adult ESOL Literacy)
Adult ESOL Literacy (i.e., teaching classes identified by programs as “literacy” classes)
Other Adult Education (non-ESOL)
K-12 ESOL
Other K-12
Other Teaching (specify):

What is the total number of hours you spent in the following professional development activities during the last year (fall 2007 through spring 2008)?

Write the total number of hours you spent in these activities. If you attended professional development that falls under multiple categories, please divide the number of hours you estimate was spent on each topic.

Round to nearest whole hour. Write ‘0’ if you participated in none.

	Fall 2007 through Spring 2008
	Number of hours (Write ‘0’ if you participated in none)
a. Teaching reading or general training on literacy instruction for ESOL learners
b. Teaching reading or general training on literacy instruction for non-ESOL learners
c. Teaching general ESOL (oral communication skills, pronunciation, vocabulary, etc.)
d. Other (specify): _______________________________________

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