OMB #:
Expiration
Date:
Education Study
Parent Questionnaire
Spring 2013
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 15 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 mandatory (citing
authority)/required to obtain or retain benefit (citing authority)
or 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 XXXX-XXXX. Note: Please do not
return the completed XXXX (cite form or other applicable reporting
mechanism) application to this address.
Your child’s name is listed on the cover. Please write his or her name here: ________________________. When you read “your child,” please think about this child only.
Where the terms “child” and “children” have been used in this questionnaire, this means children of all ages – from 5-18.
Please answer every question.
Part 1: About Your Child
This section asks questions about the child listed on the cover.
Q1. What is this child’s date of birth: |__|__| / |__|__| / |__|__|__|__|
D D M M Y Y Y Y
Q2. Is your child currently/At the end of the spring 2013 term, was your child attending school, not attending school, or being homeschooled? If [he/she] [is/was] out for school break, illness, injury, or vacation, please consider [him/her] as attending school.
Attending School 1 Skip to Q3
Being homeschooled 2 Skip to Q5
Not Attending School 3 Skip to Q2a
Q2a. Why is your child not attending school?
Completed and/or graduated High School 1 Skip to Q5
Sick/Illness 2 Skip to Q5
Taking care of family 3 Skip to Q5
Pregnant 4 Skip to Q5
Dropped out 5 Skip to Q5
Q3. What school is this child currently attending?
School Name:
School Address:
Q3a. Is the school this child is currently attending your neighborhood school?
( Check one)
Yes 1
No 2
Don’t know 3
Q4. On average, how many minutes does it take this child to get from home to school each
morning?
_____________ minutes
Part 2: Questions about This Child’s School
Q5. During this school year (2012-13), how often did you do the following in this child’s school:
( Check one box on each row)
|
Never |
Once |
2 or 3 times |
4 or more times |
|
1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
|
1 |
2 |
3 |
4 |
Q6. In the past MONTH, how often did you do the following?
( Check one box on each row)
|
Never |
Once |
2 or 3 times |
4 or 5 times |
6 or more times |
a. Help this child with his or her homework |
1 |
2 |
3 |
4 |
5 |
b. Help this child with reading or math that was not part of his or her homework |
1 |
2 |
3 |
4 |
5 |
c. Talk to this child about his or her experiences in school |
1 |
2 |
3 |
4 |
5 |
d. Work with child on a school project |
1 |
2 |
3 |
4 |
5 |
Q7. How satisfied are you with the following aspects of this child’s current school?
( Check one box per row)
|
Very dissatisfied |
Dissatisfied |
Satisfied |
Very Satisfied |
a. Location of school |
1 |
2 |
3 |
4 |
b. School safety |
1 |
2 |
3 |
4 |
c. Class sizes |
1 |
2 |
3 |
4 |
d. School facilities |
1 |
2 |
3 |
4 |
|
1 |
2 |
3 |
4 |
|
1 |
2 |
3 |
4 |
|
1 |
2 |
3 |
4 |
h. Parental support for the school |
1 |
2 |
3 |
4 |
i. Discipline |
1 |
2 |
3 |
4 |
j. Academic quality |
1 |
2 |
3 |
4 |
k. Racial mix of students |
1 |
2 |
3 |
4 |
|
1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
Q8. Overall, how safe do you feel this child’s current school is?
Very safe 1
Somewhat safe 2
Not safe 3
Q9. Does your child receive any of the following services in his/her current school?
( Check all that apply)
|
Yes |
No |
a. Before-school care |
1 |
2 |
b. After-school care |
1 |
2 |
c. Tutoring in school for math |
1 |
2 |
d. Tutoring in school for reading |
1 |
2 |
e. Federally funded free or reduced price lunch |
1 |
2 |
Q10. If your child has a physical disability, does the school address your child’s needs (e.g., ramps,
special aide)?
( Check one)
Yes 1
No 2
My child does not have a physical disability 3
Q11. If
your child has a learning disability, does the school provide your
child with accommodations
(e.g., more time on tests)?
( Check one)
Yes 1
No 2
My child does not have a learning disability 3
Q12. If your child’s primary language is not English, does the school provide support to learn English?
( Check one)
Yes 1
No 2
My child’s primary language is English. 3
Q13. If your child is struggling academically, does the school provide your child with support
(e.g., extra instruction, individualized instruction, tutoring)?
( Check one)
Yes 1
No 2
My child does not struggle academically 3
Q14. What overall grade would you give this child’s current school?
( Check one)
Excellent (A) 1
Good (B) 2
Fair (C) 3
Unsatisfactory (D) 4
Failing (F) 5
Q15. In the last month, approximately how many days did this child:
( Check one)
|
None |
1-2 Days |
3-4 Days |
5 or more days |
Don’t Know |
a. Miss school |
1 |
2 |
3 |
4 |
5 |
b. Come to school ½ hour or more late |
1 |
2 |
3 |
4 |
5 |
Q16. During this school year (2012-13), was this child ever suspended from school for disciplinary
reasons?
( Check one)
No 1
Yes 2
Don’t know 3
Q17. How far in school do you expect your child to go?
( Check one)
Less than high school completion |
1 |
Complete a high school diploma, GED or alternative high school credential |
2 |
Complete a certificate or diploma from a school that provides occupational training |
3 |
Complete an Associate’s degree |
4 |
Complete a Bachelor’s degree |
5 |
Complete a Master’s degree |
6 |
Complete a Ph.D., M.D., law degree, or other high level professional degree |
7 |
Q18. How much …
|
A Lot |
Some |
A Little |
None |
|
1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
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1 |
2 |
3 |
4 |
|
1 |
2 |
3 |
4 |
Part 3: Questions about choosing
schools
and the DC Opportunity Scholarship Program
Q19. How did you first become aware of the DC Opportunity Scholarship Program?
|
Check All That Apply |
|
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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7 |
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8 |
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9 |
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10 |
Q20. What was the most important reason in your choice of schools for this child for this school year?
|
Check Only One |
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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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7 |
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8 |
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9 |
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10 |
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11 |
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12 |
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13 |
|
14 |
Q21. What was the next most important reason in your choice of schools for this child for this school year?
|
Check Only One |
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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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7 |
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8 |
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9 |
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10 |
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11 |
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12 |
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13 |
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14 |
Q22. What was the MOST important source of information in making the choice?
|
Check Only One |
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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 |
Q23. Why was this source the most important?
|
Check Only One |
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1 |
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2 |
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3 |
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4 |
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5 |
Q24. What type of additional information do you think would have been helpful in choosing a school for this child?
|
Check All That Apply |
|
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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7 |
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8 |
Q25. Did this child get an offer of a scholarship to attend a private school through the DC Opportunity Scholarship program? ( Check one)
|
q1 |
(Go to question 29) |
|
q2 |
(Go to question 26) |
|
q3 |
(Go to question 28) |
Q26. If your child began the 2012-2013 school year at a private school with scholarship funding, did he or she switch to another school partway through the year?
( Check one)
No q1 (Go to question 29)
Yes q2 (Go to question 27)
Q27. Why did this child leave the private school he/she attended?
( Check all that apply)
|
01 |
|
02 |
|
03 |
|
04 |
|
05 |
|
06 |
|
07 |
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08 |
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09 |
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10 |
|
11 |
(Go to Question 29)
Q28. Why did this child not use the offer of the scholarship?
( Check all that apply)
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01 |
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02 |
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03 |
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04 |
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05 |
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06 |
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07 |
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08 |
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09 |
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10 |
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11 |
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12 |
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13 |
|
14 |
Q29. Do you plan to send this child to the same school next year?
( Check one)
No q1
Yes q2 (Go to Question 31)
Do not know yet q3 (Go to Question 31)
Q30. What is the main reason why this child will not be attending the same school next year?
( Check one)
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|
|
q01 |
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q02 |
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q03 |
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q04 |
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q05 |
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q06 |
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q07 |
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q08 |
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q09 |
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q10 |
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q11 |
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q12 |
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q13 |
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q14 |
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q15 |
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q16 |
|
q17 |
Part 4: Questions about the Child’s Parents or Legal Guardian
Q31. Who is completing this questionnaire? Please mark your relationship to the child:
( Check one)
Child's primary female guardian 1
Child's primary male guardian 2
Other (please specify
_____________________________) 3
Q32. For kindergarten through 12th grade, did you attend a public or private school?
|
Check Only One |
|
1 |
|
2 |
|
3 |
Q33. Were any schools you attended charter schools?
( Check one)
Yes q1
No q2
Q34. How many years have you lived in your current residence?
( Check one box)
Less than 3 months 1
3-11 months 2
1-2 years 3
More than 2 years 4
Q35. Do you currently have a job outside the home, either full-time or part-time?
( Check one box)
Yes, a full time job (35+ hours) 1
Yes, a part time job (less than 35 hours) 2
Yes, one or more part time jobs (totaling 35+ hours) 3
Not working now, but looking for work 4
Not working now and not looking for work 5
Don’t know 6
Q36. How many years and months have you worked, either part-time or full-time, since leaving school?
____Years ____Months
Part 5: Contact Information
Please Provide Your Current Contact Information:
First Name: _____________________________ MI: _____ Last Name: _________________________
Address:
Home Phone number
Cell Phone number
Email Address:
Additional Contact Information
Please provide the names and addresses for three people who are likely to know the whereabouts of the child in the future. The contact people listed do not have to be family members and can be friends and/or neighbors of the family.
Contact Information #1:
First Name: _____________________________ MI: _____ Last Name: _________________________
Address:
Home Phone number
Cell Phone number
Email Address:
Relationship to child: ____________________________
Contact Information #2:
First Name: _____________________________ MI: _____ Last Name: _________________________
Address:
Home Phone number
Cell Phone number
Email Address:
Relationship to child: ____________________________
Contact Information #3:
First Name: _____________________________ MI: _____ Last Name: _________________________
Address:
Home Phone number
Cell Phone number
Email Address:
Relationship to child: ____________________________
Thank you for completing the survey.
File Type | application/msword |
Author | Mike Puma |
Last Modified By | Sylvia Segovia |
File Modified | 2013-04-01 |
File Created | 2012-10-22 |