Mentor Questionnaire

APPENDIX A
MENTOR QUESTIONNAIRE

OMB No.: 1850-0802
Expiration Date: xx/xx/xxxx
6137-080

MENTOR
QUESTIONNAIRE
STUDY OF TEACHER
INDUCTION PROGRAMS
Induction refers to a program of professional development and support for beginning teachers. Teacher induction
programs consist of various components and activities and often include mentoring and professional development
workshops.
This form asks about your mentoring experiences and your background. For each item, please mark only one answer,
unless instructions say to “MARK (X) ALL THAT APPLY.” Thank you very much for helping us to learn more about teacher
induction.

We want you to know that:
1.

We are asking you these questions to gather information about your career decisions and
your experiences working with beginning teachers.

2.

You may skip any questions you do not wish to answer; however, we hope that you answer
as many questions as you can. Your answers to questions will not affect your eligibility for
any public programs.

3.

All responses are confidential. Your responses will be combined with those of other
mentors, and the answers you give will never be identified as yours.

Mathematica Policy Research (MPR)
Princeton, NJ
pnemeth@mathematica-mpr.com
www.mathematica-mpr.com
For questions, call Pat Nemeth at 877-840-4740
The U.S. Department of Education wants to protect the privacy of individuals who participate in surveys. Your answers will be
combined with other surveys, and no one will know how you answered the questions. This survey is authorized by law (1) Sections
171(b) and 173 of the Education Sciences Reform Act of 2002, Pub. L. 107-279 (2002); and (2) Section 9601 of the Elementary and
Secondary Education Act (ESEA), as amended by the No Child Left Behind (NCLB) Act of 2001 (Pub. L. 107-110).
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 1850-0802. The time required to complete this information collection is estimated
to average 10 minutes per respondent, including the time to review instructions, gather the data needed, and complete and review the information
collected. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S.
Department of Education, Washington, DC 20202. If you have comments or concerns regarding the status of your individual submission of this form,
write directly to: U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Washington, DC 20208.

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A. MENTORING EXPERIENCES

YOU MAY USE EITHER A PENCIL OR A PEN.
Mentoring describes a formal or informal learning relationship, usually between two individuals where the mentor
has either experience or expertise in a particular area and provides information, advice, support, and feedback to
the beginning teacher. Literacy and mathematics coaches or lead teachers often take on the role of mentor for
beginning teachers.

Questions A1-A6 refer to mentoring positions held PRIOR to the 2005-2006 school year.
A1.

A2.

Have you mentored beginning teachers?
1

! Yes

0

! No

For how many school years have you been a mentor?
|

|

A3.

GO TO A7

| YEARS

For what grade level(s) were you a mentor?
MARK (X) ALL THAT APPLY

A4.

x

! Prekindergarten

0

! Kindergarten

1

! 1st

2

! 2nd

3

! 3rd

4

! 4th

5

! 5th

6

! 6th

7

! 7th

8

! 8th

9

! Other (Please specify)

Excluding the training session which you are currently attending, have you ever attended training sessions,
workshops, or seminars to prepare you for a mentoring position(s)?
1

! Yes

0

! No

GO TO A6

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A5.

As part of training for your previous mentoring position(s), did you attend workshops or seminars on . . .
MARK (X) YES OR NO
FOR EACH

Yes

A6.

No

a. Coaching strategies? .........................................................................................

1

!

0

!

b. Content-focused coaching in literacy/language arts? ........................................

1

!

0

!

c.

Content-focused coaching in mathematics? ......................................................

1

!

0

!

d. Conducting classroom observations? ................................................................

1

!

0

!

e. Giving effective feedback? .................................................................................

1

!

0

!

f.

Leading study groups?.......................................................................................

1

!

0

!

g. Analyzing student work? ....................................................................................

1

!

0

!

h. Working with adult learners to set goals? ..........................................................

1

!

0

!

i.

Roles and responsibilities of a mentor? .............................................................

1

!

0

!

j.

Helping the beginning teacher with classroom management?...........................

1

!

0

!

k.

Helping the beginning teacher with lesson planning? ........................................

1

!

0

!

As part of your previous mentoring experience, how often did you . . .
MARK (X) ONE FOR EACH

Never
a. Observe beginning teachers and
give them feedback on their
practice? .........................................
b. Conduct/lead study groups on
teaching and learning?....................
c. Review and analyze a portfolio of
information collected by beginning
teachers? ........................................
d. Work with beginning teachers to
set goals to improve their practice?
e. Work with beginning teachers to
identify strategies for effective
instruction?......................................
f. Help beginning teachers plan
lessons?..........................................
g. Have beginning teachers observe
teaching by you or others?..............
A7.

Weekly

BiMonthly

Monthly

A Few
Times a
Year

Upon
Request as
Needed

0

!

1

!

2

!

3

!

4

!

5

!

0

!

1

!

2

!

3

!

4

!

5

!

0

!

1

!

2

!

3

!

4

!

5

!

0

!

1

!

2

!

3

!

4

!

5

!

0

!

1

!

2

!

3

!

4

!

5

!

0

!

1

!

2

!

3

!

4

!

5

!

0

!

1

!

2

!

3

!

4

!

5

!

How did you obtain this current mentor position?
1

! Applied voluntarily, on my own

2

! Someone at the district approached me to apply for the position

3

! Assigned

4

! Other (Please specify)

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B. PROFESSIONAL PREPARATION

B1.

Please describe your postsecondary degrees in the chart below.
A.

B.

C.

D.

E.

Year Degree
Received

Type of Degree

Name of College
or University

Major Field of Study

Minor Field of Study

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B2.

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1

! Associate’s

2

! Bachelor’s

3

! Master’s

4

! Other (Please specify)

1

! Associate’s

2

! Bachelor’s

3

! Master’s

4

! Other (Please specify)

1

! Associate’s

2

! Bachelor’s

3

! Master’s

4

! Other (Please specify)

Are you currently working toward an advanced degree (for example, Master’s, Ed.D., or Ph.D.) or additional
credits?

1

! Yes

1

! Degree:

0

! No

2

! Additional Credits

a. NAME OF COLLEGE OR UNIVERSITY:

b. MAJOR FIELD OF STUDY:

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B3.

From the list below, select the areas in which you are certified.
MARK (X) ALL THAT APPLY

B4.

B5.

1

! General elementary education

2

! Bilingual education

3

! Special education (Please specify area of certification)

4

! A specific subject area or areas (Please specify)

5

! Other (Please specify)

6

! Not certified

Are you working toward additional certification?
1

! Yes

0

! No

(Please specify)

Have you been certified through the National Board of Professional Teaching Standards (NBPTS)?
2

! Yes

1

! No, but I’m working toward NBPTS certification now

0

! No

(Please specify area of certification)

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(Please specify area of certification)

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B6.

For how many school years have you been a teacher?
|

B7.

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| NUMBER OF YEARS

Please list each school at which you have been a classroom teacher prior to becoming a mentor for the
2005-2006 school year. For each school listed, indicate the grade level you taught and the years you
taught at that grade level.
Date Start

Grade-Level Taught

Month

School Name

Date End

Year

Month

Year

1.

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2.

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3.

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4.

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5.

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6.

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B8.

Please indicate any other education positions you have held, for example, a district-level position.
Date Start

Date End

Position Held

Month

1.

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Year

Month

Year

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C. BACKGROUND INFORMATION

C1.

In what year were you born?
|

C2.

C3.

C4.

C5.

|

|

|

| YEAR

What is your ethnic background?
1

! Hispanic or Latino

2

! Not Hispanic or Latino

Mark the box or boxes that best describes your race.
1

! American Indian or Alaska Native

2

! Asian

3

! Black or African American

4

! Native Hawaiian or Other Pacific Islander

5

! White

Are you male or female?
1

! Male

2

! Female

Please PRINT your name, home address, and telephone number. This information will be used to contact you
if there are questions about survey responses.
Your Name:
Street Address:
City:

State:

Zip Code:

Home Telephone:

(| | | |) - |
Area Code

|

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|-| |
Number

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Cell Phone Number:

(| | | |) - |
Area Code

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Number

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Home Email Address:
Work Email Address:

Thank you for completing this survey.
Please return this survey to the Mathematica representative at the training.

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