Appendix G - Teacher Student Rating Form

TITLE I EARLY CHILDHOOD LANGUAGE DEVELOPMENT STUDY

Teacher Student Report

April 28, 2011

Notice of Confidentiality

Information collected for this study come under the confidentiality and data protection requirements of the Institute of Education Sciences (The Education Sciences Reform Act of 2002, Title I, Part E, Section 183). Information that could identify an individual or institution will be separated from the survey responses submitted, kept in secured locations, and be destroyed as soon as they are no longer required. Survey responses will be used only for research purposes. The reports prepared for the study will summarize findings across individuals and institutions and will not associate responses with a specific district, school, or person.

Conducted by: Mathematica Policy Research

www.mathematica-mpr.com

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1850-0871. Note: Please do not return the completed questionnaire to this address.

A1. Are you currently the Reading/Language Arts teacher for this student?

1 □ Yes GO TO A6

0 □ No

A2. What is the main reason you are no longer this student’s Reading/Language Arts teacher?

1 □ Student moved to another class in the same school

2 □ Student moved to another school GO TO A4

3 □ Student was never in my class/I don’t know this student GO TO A5

A3. What is the name of the teacher whose Reading/Language Arts class this student currently attends?

Name:

A4. Please record the last date this student was in your Reading/Language Arts class.

| | | / | | | / | | | | |

Month Day Year

A5. Thank you.

A6. During this school year (2011-2012), how many days has this student been…

(Drop Down Menu Range 0-20 and then more than 20)

	NUMBER OF DAYS
a. Absent from class?	| | |
b. Sent to the office or removed from your class due to behavior problems?	| | |

MPR’s agreement with the publisher/developer of this set of items does not allow us to share the items publicly without prior written approval.

C1. Was this student retained in a grade at the end of the last school year (2010-2011)?

1 □ Yes

0 □ No

C2. During this school year (2011-2012), has this student received instruction and/or related services in any of the following types of programs in your school during the school day?

	MARK (X) ONE PER ROW
	YES	NO	SERVICE NOT PROVIDED
a. Individual tutoring in reading	1 □	0 □	2 □
b. Pull-out small group reading instruction	1 □	0 □	2 □
c. English as a Second Language (ESL) program (designed to teach English to those whose home language is not English)	1 □	0 □	2 □
d. Learning a language other than English	1 □	0 □	2 □
e. Gifted and talented program	1 □	0 □	2 □
f. Special education, speech, or related services	1 □	0 □	2 □
g. Individual or group counseling	1 □	0 □	2 □

C3. During this school year (2011-2012), has this student received any of the following Supplemental Educational Services before school or after school to help with reading/language arts?

	MARK (X) ONE PER ROW
	YES	NO	SERVICE NOT PROVIDED BEFORE OR AFTER SCHOOL
a. Individual tutoring in reading/language arts	1 □	0 □	2 □
b. Small group reading/language arts instruction	1 □	0 □	2 □
c. English as a Second Language (ESL) program (designed to teach English to those whose home language is not English)	1 □	0 □	2 □
d. Help with homework	1 □	0 □	2 □
e. Help with test-taking skills	1 □	0 □	2 □

D1. Thinking specifically about this student’s family, how often did the following happen during this school year (2011-2012)?

	Mark (X) ONE PER ROW
	Never	1-2 times	3 OR MORE TIMES
a. Information was sent home to this student’s family about what the student is learning at school (separate from report card)	0 □	1 □	2 □
b. You suggested ways parent could help this student do well at school	0 □	1 □	2 □
c. This student’s parent asked how (he/she) could help the student with schoolwork	0 □	1 □	2 □
d. You invited this student’s parent to school	0 □	1 □	2 □
e. You called this student’s parent or sent a note to let (he/she) know that the student did well at something	0 □	1 □	2 □
f. You called this student’s parent or sent a note to let (he/she) know that the student was having problems	0 □	1 □	2 □
g. This student’s parent volunteered to help in the classroom	0 □	1 □	2 □
h. This student’s parent came to parent-teacher conferences	0 □	1 □	2 □
i. This student’s parent visited the classroom	0 □	1 □	2 □
j. This student’s parent called or came to see you.	0 □	1 □	2 □

OMB No.: 1850-0871

Expiration Date: xx/xx/xxxx