Instructor Background Characteristics Form

Strengthening Adult Reading Instructional Practices	OMB#:	Exp. Date:
	Code # — —

Instructor Background Characteristics Form

Name of Instructor: _____________________________________ Date:

Name of Program: _________________ City/State:

Please complete the requested information or check the category for each item that best describes your background.

1. Gender: _____Male _____Female

2. Highest Level of Education:

_____Less than B.A. _____B.A./B.S M.A./M.S. Ph.D./Ed.D

3. Academic Area of Specialty: Please put your degree(s) next to the relevant academic area

Degree Degree

Adult Education History

Business Language/Linguistics

Education Guidance/Counseling

Education/Elementary Mathematics

Education/Secondary Communication Arts

Education/Reading Psychology

Special Education Social Science (Sociology, Anthropology,

English Economics, Political Science)

ESL Social Work

Other (Specify: )

4. Please list any certifications that you have and the areas in which you are certified:

5. Birth Date:

6. Employment Status in this Program:

_____Full-time _____Number of hours per week considered full-time

_____Part-time _____Number of hours per week considered part-time

7. Do you receive benefits? Yes No If yes, list benefits:

8. Number of Years Teaching in Adult Ed. _____# of years

9. Number of Years in Current Program # of years

10. Number of Years Teaching Reading # of years

11. Number of Years Teaching this Class # of years

12. Other classes you currently teach in this program (write “none” if none are taught):

13. Do you currently teach in any other adult education programs? Yes No

If yes, how many classes and which classes do you teach? # of classes

Names of classes:

14. Past Teaching: Types of classes taught in Adult Education prior to this year and not including the current reading class:

_____ABE - Reading _____ABE – Math Other: (specify) _____ABE - General _____ABE – Writing

_____Pre-GED _____ESL

15. Have you ever participated in formal training in reading instruction other than the STAR training: Yes No

If yes, which program, when, where, and what materials were used? (If more than one training session was attended, list additional sessions on back of this sheet.)

Program/Training Session:

When/Where:

Materials Used:

16. List the STAR training sessions that you have attended:

Session Name: Location: Month/Year

17. Have you participated in any of the following during the past four years?

(If any of these opportunities are not available to you, write “NA” next to the activity.)

Local ABE program committee work

State adult education committees or development work sponsored by state adult ed. office

State adult education association-sponsored committees

National working groups sponsored by OVAE or contractors working for OVAE

Other leadership activities: Describe:

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