Program Data Form

Adult ESL Literacy Impact Study

Data to Be Collected at Intake

• Name

• Address

• Phone (up to four numbers)

• Type (home, work, cell)

• E-mail address

• Alternative contact information (spouse, relatives, friends)

  • Relationship of contact to student

• Date of birth

• Sex

• Male

• Female

• Ethnicity

• Hispanic or Latino

• Not Hispanic or Latino

• Race

• White

• Black or African American

• Asian

• Native Hawaiian or Other Pacific Islander

• American Indian or Alaska Native

• Years in the U.S.

• Employment status

• Employed

• Unemployed

• Not in the labor force voluntarily (retired, student, homemaker)

• Country of origin

• Haiti

• Mexico

• China

• El Salvador

• Somalia

• Laos

• Ethiopia

• Guatemala

• Dominican Republic

• Honduras

• Other (Specify): ______________________

• First language(s)

• Spanish

• Haitian Creole

• French

• Somali

• Hmong

• Other (Specify): _____________________

• Other languages spoken at home (up to three)

• Total years of education

• Years of education in the U.S.

• Have you taken any other ESL classes in the U.S. before?

• If yes, when was the last time you took another ESL class:

  • Less than 6 months ago

  • At least 6 months but less than a year ago

  • At least 1 year but less than 2 years ago

  • At least 2 years but less than 5 years ago

  • 5 or more years ago

• Are you currently enrolled in another ESL class?

• Are you currently enrolled in school other than ESL?

• Are you enrolling in this class with:

  • Husband or wife

• Brother or sister

• Other relative

• Roommate/housemate

• Friend

• Other (Specify): ______________________

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