Early Childhood Longitudinal Study, Kindergarten Class of 2010-11 (ECLS-K:2011) Spring Fifth-Grade National Data Collection

Appendix D & E Teacher red ECLSK-2011 Spring 5th Grade

Early Childhood Longitudinal Study, Kindergarten Class of 2010-11 (ECLS-K:2011) Spring Fifth-Grade National Data Collection

OMB: 1850-0750

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APPENDIX D
FIFTH-GRADE
TEACHER-LEVEL QUESTIONNAIRE (TQ)

Early Childhood Longitudinal Study, Kindergarten Class of 2010-11
(ECLS-K:2011)

Spring Fifth-Grade National Data Collection
OMB Clearance Package
#1850-0750 v.18

Draft

Spring 2016
Teacher Questionnaire
Prepared for the U.S. Department of Education
National Center for Education Statistics by:
Westat
Rockville, Maryland
Use a black or blue ball point pen to complete this questionnaire.

RETURN THIS COMPLETED QUESTIONNAIRE IN THE SEALED
TYVEK® ENVELOPE DIRECTLY TO YOUR SCHOOL COORDINATOR
OR AN ECLS-K:2011 STAFF MEMBER. DO NOT MAIL THIS
QUESTIONNAIRE UNLESS YOU ARE ASKED TO DO SO BY STUDY
STAFF AND ARE PROVIDED WITH AN ENVELOPE FOR MAILING.

S_ID

T_ID

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 voluntary survey is
1850-0750. Approval expires XX/XX/XXXX. The time required to complete this
survey is estimated to average 13 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed,
and complete and review the survey. If you have any comments concerning
the accuracy of the time estimate or suggestions for improving this survey, or
any comments or concerns regarding the status of your individual submission
of this survey, please write to: Early Childhood Longitudinal Study, National
Center for Education Statistics, 1990 K Street, N.W., Washington, D.C. 200065574.

The collection of information in this survey is authorized by 20 U.S.
Code, Section 9543. Participation is voluntary. You may skip questions
you do not wish to answer; however, we hope that you will answer as
many questions as you can. Your responses are protected from
disclosure by federal statute (20 U.S. Code, Section 9573). All
responses that relate to or describe identifiable characteristics of
individuals may be used only for statistical purposes and may not be
disclosed, or used, in identifiable form for any other purpose except as
required by law. Data will be combined to produce statistical reports.
No individual data that links your name, address, telephone number,
or identification number with your responses will be included in the
statistical reports.

Draft

Dear Teacher,
This questionnaire is an important part of a major longitudinal study of children’s early educational
experiences beginning with kindergarten and continuing through grade 5. You have received this
questionnaire because you teach one or more of the children who are participants in this study.
The Early Childhood Longitudinal Study, Kindergarten Class of 2010-2011 (ECLS-K:2011) is
collecting information from teachers of children who are in the study to investigate the relationship
Dear Teacher,
between
children’s academic progress and various school, classroom, teacher, and home characteristics.
Taking part in the study is voluntary. You may stop at any time or choose not to answer a question you do
not
to answer.is However,
onlypart
you of
can
provide
this information.
weearly
realize
you are very
Thiswant
questionnaire
an important
a major
longitudinal
study ofAlthough
children’s
educational
busy,
we urgebeginning
you to complete
this questionnaire
as completely
and
accurately
possible.
The
experiences
with kindergarten
and continuing
through
grade
5. Youas
have
received
this
information
you
provideyou
is being
for research
purposes
will be protected
from
questionnaire
because
teach collected
one or more
of the children
whoonly
are and
participants
in this study.
disclosure to the fullest extent allowable by law (Education Sciences Reform Act of 2002, 20 U.S.C. § 9573).
Information
from multiple
individualsStudy,
will beKindergarten
combined to produce
reports;
no information
that
The Early Childhood
Longitudinal
Class of statistical
2010-2011
(ECLS-K:2011)
is
identifies
will be included
in any reports
or provided
parents, or
other
school staff.
collectingyou
information
from teachers
of children
who are to
in students,
the study their
to investigate
the
relationship
between children’s academic progress and various school, classroom, teacher, and home characteristics.
Please
answers
directly onYou
themay
questionnaire
marking
the appropriate
answer
(as
Takingrecord
part inyour
the study
is voluntary.
stop at anyby
time
or choose
not to answer
a question
you do
instructed
onanswer.
page 4)However,
or by writing
the information.
space provided.
Your best
estimates
not want to
onlyyour
you responses
can provideinthis
Although
we realize
youare
are very
acceptable
answers.
busy, we urge
you to complete this questionnaire as completely and accurately as possible. The
information you provide is being collected for research purposes only and will be protected from
disclosure to the fullest extent allowable by law (Education Sciences Reform Act of 2002, 20 U.S.C. § 9573).
Information from multiple individuals will be combined to produce statistical reports; no information that
DEFINITIONS
identifies you will be included in any reports or provided to students, their parents, or other school staff.
For the purposes of this study, the following definition applies:
Please record your answers
directly YOU
on theVERY
questionnaire
marking
the appropriate
answer (as
THANK
MUCHbyFOR
YOUR
HELP.
instructed
on
page
4)
or
by
writing
your
responses
in
the
space
provided.
Your
best
estimates
are
 English language learner (ELL): A student whose native language is one other than
acceptable
answers.
English
and whose skills in listening, speaking, reading, or writing English are such that he
or she has difficulty understanding school instruction in English.

THANK YOU VERY MUCH FOR YOUR HELP.

Draft

MARKING DIRECTIONS
PLEASE
READ CAREFULLY
USE AOR
BLACK
BLUE
BALLPEN
POINT
TO LEAD
PLEASE READ
CAREFULLY
AND USEAND
A BLACK
BLUEOR
BALL
POINT
ORPEN
A SOFT
COMPLETE
THIS
QUESTIONNAIRE.
DO
NOT
USE
PENCIL
OR
FELT-TIP
PEN.
(#2) PENCIL TO COMPLETE THIS QUESTIONNAIRE. DO NOT USE A FELT-TIP PEN.

MARKING BOXES
It is important that you mark an “X” in the box next to your answers and print clearly.
Shown below is the correct way to mark your answers, along with examples of incorrect ways.
Correct Mark:

Incorrect Marks:
Light and thin, outside the box, thick or scrawled.

How to Change an Answer:
Completely black out the box of the incorrect answer and mark an “X” in the box next to the
correct answer.

PRINTING ANSWERS IN BOXES:
Answers should be printed clearly and should not touch or cross any of the box lines. Do not
cross zeroes or sevens. That is, do not write a zero with a line through it like this –
write a seven with a line through it like this – 7.
Write one number per box like this:

Write words like this:

John Smith

0, and do not

Draft

SECTION A. STUDENT, SCHOOL, AND STAFF ACTIVITIES
A1.

Which of the following subjects do you teach during this school year? MARK ONE RESPONSE ON
EACH ROW.
Yes

a. Reading/language arts
b. Mathematics
c. Science
d. Social studies

A2.

How often does the typical child in your class(es) usually work on lessons or projects in the
following general subject areas, whether as a whole class, in small groups, or in individualized
arrangements? MARK ONE RESPONSE ON EACH ROW.

Never

Less than
once a 1 day a
week
week

a. Reading and language arts
b. Mathematics
c. Social studies
d. Science
e. Music
f.

Art

g. Physical education
h. Dance/creative movement
i.

Theater/creative dramatics

Foreign language (excluding
English for ELL students)

2 days
a week

3 days
a week

4 days
a week

5 days
a week

Draft

A3.

On the days children work in these areas, how much time does the typical child in your class(es)
usually work on lessons or projects in the following general subject areas? MARK ONE RESPONSE ON
EACH ROW.
Less
Not
than ½
applicable/ hour a
never
day

½ hour
to less 1 to less
than 1
than 1
½ hours
hour

1 ½ to
less
than 2
hours

a. Reading and
language arts
b. Mathematics
c. Social studies
d. Science
e. Music
f.

Art

g. Physical education
h. Dance/creative
movement
i. Theater/creative
dramatics
j. Foreign language
(excluding English
for ELL students)

A4.

How many days a week do children have recess? MARK ONE RESPONSE.
Zero (no recess on any day) (SKIP TO Q A6)
One
Two
Three
Four
Five
Other/Varies by week

2 to less
than 2
½ hours

2 ½ to
less
than 3
hours

3 hours
or more

Draft

A5.

On days when children have recess, between the school day starting time and the dismissal time,
how many times a day do children have recess? MARK ONE RESPONSE.
One
Two
Three
Four
Five
Other/Varies by day

A6.

What percentage of children in your class(es) have parents who participate in the following
activities? MARK ONE RESPONSE ON EACH ROW.
0%

1-25%

26-50%

51-75%

76% or
more

a. Attend teacher-parent conferences
b. Volunteer regularly to help in your
classroom or another part of the school
c. Attend open houses or parties
d. Attend art/music events or demonstrations

A7.

How important is each of the following in evaluating the children in your class(es) for reporting
to parents? MARK ONE RESPONSE ON EACH ROW.
Not
important
a. Individual child's achievement relative
to the rest of the class
b. Individual child's achievement relative
to local, state, or professional standards
c. Individual improvement or progress
over past performance
d. Effort
e. Class participation
f.

Daily attendance

g. Classroom behavior or conduct
h. Cooperativeness with other children
i.

Ability to follow directions

Somewhat
important

Very
important

Extremely
important

Draft

SECTION B. VIEWS ON SCHOOL CLIMATE AND SCHOOL ENVIRONMENT
B1.

Please indicate the extent to which you agree or disagree with each of the following statements
about your school. MARK ONE RESPONSE ON EACH ROW.
Neither
Strongly
Strongly
agree nor
disagree Disagree
Agree
agree
disagree
a. The level of child misbehavior (for
example, noise, horseplay, or fighting
in the halls or cafeteria) in this school
interferes with my teaching.
b. Many of the children I teach are not
capable of learning the material I am
supposed to teach them.
c. Parents are supportive of school staff.
d. There is a great deal of cooperative
effort among the staff members.
e. There is a consensus among
administrators and teachers on goals
and expectations.
f.

The academic standards at this school
are too low.

g. The school administrator sets priorities,
makes plans, and sees that they are
carried out.
h. The school administration's behavior
toward the staff is supportive and
encouraging.
B2.

To what extent do you agree or disagree with each of the following statements? MARK ONE
RESPONSE ON EACH ROW.
Neither
Strongly
Strongly
agree nor
disagree Disagree
Agree
agree
disagree
a. The attitudes and habits students bring
to my class(es) greatly reduce their
chances for academic success.
b. My success or failure in teaching is due
primarily to factors beyond my control
rather than to my own effort or ability.
c. The amount a student can learn is
primarily related to family background.
d. I really enjoy my present teaching job.
e. If I could start over, I would choose
teaching again as my career.

Draft

SECTION C. TEACHER BACKGROUND
C1.

What is your gender? MARK ONE RESPONSE.
Male
Female

C2.

In what year were you born? WRITE IN YEAR BELOW.

1 9
YEAR
C3.

Are you Hispanic or Latino? MARK ONE RESPONSE.
Yes
No

C4.

Which best describes your race? MARK ONE OR MORE RESPONSES TO INDICATE WHAT YOU CONSIDER
YOURSELF TO BE.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Draft

C5.

Counting this school year, how many years have you taught each of the following grades and
programs, including years in which you taught part time?
WRITE THE NUMBER OF YEARS TO THE NEAREST FULL SCHOOL YEAR. IF THIS IS YOUR FIRST YEAR
TEACHING, WRITE "1." WRITE "0" IF YOU HAVE NEVER TAUGHT THE GRADE OR PROGRAM LISTED.
Total years
grade or program taught
a. Preschool or kindergarten
b. First grade
c. Second grade
d. Third grade
e. Fourth grade
f.

Fifth grade

g. Sixth grade or higher
h. English as a Second Language (ESL), bilingual
education, and/or dual language program

C6.

Special education program

Program for gifted children

Counting this school year, how many total years have you been a schoolteacher, including years in
which you taught part time? WRITE THE NUMBER OF YEARS TO THE NEAREST FULL SCHOOL YEAR. IF
THIS IS YOUR FIRST YEAR, WRITE "1."
Year(s)

C7.

Is this school year the first year you have taught in this school? MARK ONE RESPONSE.
Yes
No

Draft

C8.

What is the highest level of education you have completed? MARK ONE RESPONSE.
Did not complete high school (SKIP TO Q C11)
High school diploma or equivalent/GED (SKIP TO Q C11)
Some college or technical or vocational school (SKIP TO Q C11)
Associate's degree
Bachelor's degree
Master's degree
An advanced professional degree beyond a master's degree (for example, Ph.D., MD, Ed.D.)

C9.

If you have an associate's or bachelor's degree, indicate your undergraduate major field of study.
MARK YES OR NO ON EACH ROW.
Yes
a. Early childhood education
b. Elementary education
c. English
d. Reading and/or language arts
e. Curriculum and instruction
f.

Mathematics education

g. Mathematics
h. Science education
i.

Life science

Physical science

k. Earth science
l.

Special education

m. Other education-related major (for example, secondary education,
educational psychology, administration, music education, etc.)
n. Non-education major (for example, history, etc.)

Draft

C10.

If you have a graduate degree, indicate the major field of study of your highest level graduate
degree. MARK YES OR NO ON EACH ROW.
Yes

a. Early childhood education
b. Elementary education
c. English
d. Reading and/or language arts
e. Curriculum and instruction
f.

Mathematics education

g. Mathematics
h. Science education
i.

Life science

Physical science

k. Earth science
l.

Special education

m. Other education-related major (for example, secondary education,
educational psychology, administration, music education, etc.)
n. Non-education major (for example, history, etc.)

C11.

Have you ever taken a college course that addressed issues related to the following? MARK YES OR
NO ON EACH ROW.
Yes
a. Using published research evidence to identify and select effective
interventions and supports for students
b. Using formal assessment data to inform the choice of READING
interventions and supports for students
c. Using formal assessment data to inform the choice of MATH
interventions and supports for students
d. Using data to inform the choice of behavioral interventions and
supports for students

Draft

C12.

Which of the following describes the teaching certificate you currently hold in THIS state? MARK
ONE RESPONSE.
Regular or standard state certificate or advanced professional certificate
Certificate issued after satisfying all requirements except the completion of a probationary
period
Certificate that requires some additional coursework, student teaching, or passage of a test
before regular certification can be obtained
Certificate issued to persons who must complete a certification program in order to continue
teaching
I do not hold any of the above certifications in THIS state.

C13.

Date Questionnaire Completed:

2 0 1 6
MONTH

DAY

YEAR

THANK YOU FOR YOUR COOPERATION!

Draft

For Office Use Only
C - No DR

C - DR Comp

C - DR Ref

Ref

Draft

APPENDIX E
FIFTH-GRADE
SUBJECT-SPECIFIC CHILD-LEVELTEACHER
QUESTIONNAIRES (TQCs)

Early Childhood Longitudinal Study, Kindergarten Class of 2010-11
(ECLS-K:2011)

Spring Fifth-Grade National Data Collection

OMB Clearance Package
#1850-0750 v.18

Draft

Spring 2016
Reading and Language Arts
Teacher Questionnaire
Child Level
Prepared for the U.S. Department of Education
National Center for Education Statistics by:
Westat
Rockville, Maryland
Use a black or blue ball point pen to complete this questionnaire.

S_ID
C_ID

T_ID

Link_ID

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 voluntary survey is
1850-0750. Approval expires XX/XX/XXXX. The time required to complete this
survey is estimated to average 26 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed,
and complete and review the survey. If you have any comments concerning
the accuracy of the time estimate or suggestions for improving this survey, or
any comments or concerns regarding the status of your individual submission
of this survey, please write to: Early Childhood Longitudinal Study, National
Center for Education Statistics, 1990 K Street, N.W., Washington, D.C. 200065574.

Draft

DEFINITIONS
For the purposes of this study, the following definitions apply:
Individualized Education Program (IEP): A written statement of the educational program
designed to meet the individual needs of a school-aged child with a disability that is judged to
affect the child’s educational performance. Children who receive special education services
under the Individuals with Disabilities Education Act (IDEA) are expected to have an IEP.
English language learner (ELL): A student whose native language is one other than English and
whose skills in listening, speaking, reading, or writing English are such that he or she has
difficulty understanding school instruction in English.

Draft
1

TYPES OF LANGUAGE INSTRUCTION EDUCATIONAL PROGRAMS (LIEPS)
Programs that focus on developing students' literacy in two languages

Two-way immersion program (TWI) or two-way bilingual program: The goal of these programs is to
develop strong skills and proficiency in both students' home language and English. These programs may
also be called dual language programs. These programs include students whose native language is not
English (but who all speak the same non-English language) and students whose native language is English.
Instruction is provided in both languages, typically starting with a smaller proportion of instruction in
English, and gradually moving to half of the instruction in each language. Students typically stay in these
programs throughout elementary school.
Developmental bilingual program, late exit transitional program, or maintenance bilingual education
program: The goal of these programs is to develop some skills and proficiency in students' home language
and strong skills and proficiency in English. Content is taught in both languages by teachers fluent in both
languages. These programs may also be called dual language programs. Instruction at lower grades is in
the students' home language with a gradual transition to English. Students typically transition into
mainstream classrooms with their English-speaking peers. The programs can vary in the focus placed on
acquiring literacy in students' home language, but students generally do continue to receive some degree
of support in their home language after the transition to English classrooms.
Transitional program, early exit bilingual program, or early exit transitional program: The goal of these
programs is to develop English proficiency skills as soon as possible, without delaying learning of
academic core content. Instruction begins in students' home language but rapidly moves to English.
Students typically are transitioned into mainstream classrooms with their English-speaking peers as soon
as possible.
Heritage language program or indigenous language program: The goal of these programs is to develop
literacy in two languages. Content is taught in both languages by teachers fluent in both languages.
These programs typically target non-English speakers with weak literacy skills in their home language.
Programs that focus on developing students' literacy solely in English
Sheltered English instruction or content-based English as a Second Language (ESL) program: The goal of
these programs is to develop proficiency in English while learning content in an all-English setting.
Students from various linguistic and cultural backgrounds can be in the same class. Instruction is adapted
to students' proficiency in English and is supported by visual aids and support in the students' home
languages as available. Fully developed prototypes of this program include Sheltered Instruction
Observational Protocol (SIOP) and Specially Designed Academic Instruction in English (SDAIE).
Structured English Immersion (SEI): The goal of SEI is to develop fluency in English. This program usually
serves only English language learners. All instruction is in English, though the instruction is adjusted to the
English proficiency level of students so subject matter is comprehensible. Teachers may have some
receptive skills in the students' home language(s) and generally use sheltered instructional techniques.
Pull-out English as a Second Language (ESL) or English Language Development (ELD): The goal of
these programs is to develop fluency in English. ELL students leave their mainstream classroom for part
of the day to receive ESL instruction, which generally focuses on grammar, vocabulary, and
communication skills, not academic content. There typically is no support provided for students' home
languages.
Push-in English as a Second Language (ESL) program: The goal of push-in ESL is to develop fluency in
English. Students receive ESL instruction in a mainstream classroom, with instruction in English with some
native language support if needed. The ESL teacher or an instructional aide provides clarification,
translation if needed, and uses ESL strategies.

THANK YOU VERY MUCH FOR YOUR HELP.
1

National Clearinghouse for English Language Acquisition,
http://www.ncela.us/files/uploads/5/Language_Instruction_Educational_Programs.pdf

Draft

Incorrect Marks:
Light and thin, outside the box, thick or scrawled.

How to Change an Answer:
Completely black out the box of the incorrect answer and mark an “X” in the box next to the
correct answer.

Write words like this:

John Smith

0, and do not

Draft

PART 1:
Please answer the questions in Part 1 about the child identified on the
cover of this questionnaire.

Draft

SECTION A. SOCIAL SKILLS
Social Skills
Twenty-six items ask teachers to rate children in their classroom on social skills (including their ability to
exercise self-control, interact with others, resolve conflict, and participate in group activities); problem
behaviors (e.g., fighting, bullying, arguing, anger, depression, low self-esteem, impulsiveness, etc.); and
learning dispositions or “approaches to learning” (e.g., curiosity, selfdirection, and inventiveness). The
social skills items and the problem behavior items are not listed as they are copyright protected. The
learning disposition items are not copyright protected and are listed below.
Source: Social Skills Rating System (SSRS). Copyright © 1990 NCS Pearson. Adapted with permission. All rights reserved.

Approaches to Learning Scale items
The teacher indicated how frequently the child exhibited the following behaviors. The response scale
included four points ranging from “never” to “very often,” and there was also a “no opportunity to observe”
option.

k. Keeps belongings organized.

n. Shows eagerness to learn new things.
o. Works independently.

Draft

SECTION A. SOCIAL SKILLS (continued)

u. Easily adapts to changes in routine.

w. Persists in completing tasks.
x. Pays attention well.
y. Follows classroom rules.

Draft

A2.

Please indicate how often each of these items applies to the child identified on the cover of this
questionnaire. MARK ONE RESPONSE ON EACH ROW.
Doesn't apply

Sometimes applies

Certainly applies

Seldom displays
this behavior

Occasionally displays
this behavior

Often displays
this behavior

a. Likes to come to school
b. Dislikes school
c. Has fun at school
d. Likes being in school
e. Seems unhappy in school
f.

Enjoys most classroom activities

g. Groans or complains about suggested activities
Source: Teacher version of the School Liking and Avoidance Questionnaire ﴾
SL
AQ;Ada
pt
edf
r
om L
add& Pr
i
c
e,1987;L
add,1990﴿

Draft

SECTION B. CLASSROOM BEHAVIORS
Please answer the following questions about the child identified on the cover of this questionnaire.
B1.

Please read each statement and decide whether it is a "true" or "untrue" description of this child's
reaction to a number of situations within the past six months. If you cannot answer one of the
items because you have never seen the child in that situation, then mark "not applicable."

The child:

Almost
always
untrue

Usually
untrue

Sometimes
true,
sometimes
untrue

Usually
true

Almost
always
true

Not
applicable

a. Is easily distracted when listening
to a story.
b. Can stop him/herself when s/he is
told to stop.
c. Looks around the room when doing
school work.
d. Can stop him/herself from doing
things too quickly.
e. When working on an activity, has a
hard time keeping her/his mind on it.
f.

Has an easy time waiting.

g. Has a hard time paying attention.
h. Has a hard time waiting his/her turn
to talk when excited.
i.

Needs to be told to pay attention.

Gets distracted when trying to pay
attention in class.

k. Likes to plan carefully before doing
something.
l.

Is good at following directions.

m. Has a hard time slowing down
when rules say to walk.
Source: Adapted from the Temperament in Middle Childhood Questionnaire. © 2004 Jennifer Simonds and Mary K. Rothbart, University of
Oregon. Used with permission.

Draft

SECTION C. PEER RELATIONSHIPS
Please answer the following questions about the child identified on the cover of this questionnaire.
C1.

For the items below, please think about the friends with whom the child identified on the cover of
this questionnaire has associated the most during the past month or two. Please indicate how
true you think each of these items is for this group of children. If you cannot answer these items
because the child has not usually associated with a group of other children in the past month or
two, then mark "Not applicable." MARK ONE RESPONSE ON EACH ROW.

Almost
always
untrue

Usually
untrue

Sometimes
true,
sometimes
untrue

Usually
true

Almost
always
true

Not
applicable

a. This is a good group of kids
b. I worry when this child is with this
group
of kids
c. Some of these kids are a bad
influence
on this child
d. These kids must be closely supervised
by an adult
e. These kids get into trouble
f.

These kids are excellent students

g. These kids are hard workers
h. This child has a fun time with this
group
of children
i. Most of these kids are kind to other
children
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Draft

C2.

Please indicate how often each of these items applies to the child identified on the cover of this
questionnaire, particularly in the context of his or her behavior with peers. MARK ONE RESPONSE
ON EACH ROW.
Doesn't apply

Sometimes applies

Certainly applies

Seldom displays
this behavior

Occasionally displays
this behavior

Often displays
this behavior

a. Seems concerned when other
children are distressed.
b. Is not chosen as playmate by peers.
c. Peers avoid this child.
d. Is kind toward peers.
e. Is excluded from peers' activities.
f.

Is cooperative with peers.

g. Shows concern for moral issues (for
example, fairness, welfare of others).
h. Is ignored by peers.
i.

Offers help or comfort when other
children are upset.

Draft

C3.

During this school year, how often have other students ... MARK ONE RESPONSE ON EACH ROW.
Never

Rarely

Sometimes

Often

Very often

a. Teased, made fun of, or called
this student names?
b. Told lies or untrue stories about
this student?
c. Pushed, shoved, slapped, hit, or
kicked this student?
d. Intentionally excluded or left this
student out from playing with
them?

C4.

During this school year, how often has this student ... MARK ONE RESPONSE ON EACH ROW.
Never

Rarely

Sometimes

Often

Very often

a. Teased, made fun of, or called
other students names?
b. Told lies or untrue stories about
other students?
c. Pushed, shoved, slapped, hit, or
kicked other students?
d. Intentionally excluded or left other
students out from playing with him
or her?
Sour
c
e:Es
pel
age,D.L
.& Hol
t
,M.﴾
2001﴿
.Bul
l
y
i
ngandpeerv
i
c
t
i
mi
z
at
i
ondur
i
ngear
l
yadol
es
c
enc
e:Peeri
nf
l
uenc
esand
psychosocial correlates. Journal of Emotional Abuse,
2,123‐
142.Adapt
eda
ndus
edwi
t
hper
mi
s
s
i
on.

C5.

Thinking about the child identified on the cover of this questionnaire compared to a typical
child in his/her grade, please evaluate this child in the following areas. MARK ONE RESPONSE ON
EACH ROW.
Very
poor

Somewhat
poor

Average

Good

Very
good

a. Understands others' feelings
b. Accurately interprets what a peer is
trying to do
c. Generates good quality solutions to
interpersonal problems
d. Is aware of the effects of his/her
behavior on others
Sour
c
e:Pi
er
c
e,K.M.
,Hamm,J
.V.
,& Vandel
l
,
D.L
.﴾
1999﴿
.Ex
per
i
enc
esi
naf
t
er
‐
s
c
hoolpr
ogr
amsandc
hi
l
dr
en'
sadj
us
t
menti
n
f
i
r
s
t
‐
gr
adec
l
as
s
r
ooms
.Child Development, 70,
756‐
767.

Draft

SECTION D. STUDENT INFORMATION
Please answer the following questions about the child identified on the cover of this questionnaire.
D1.

Are you this child's primary teacher in the following subject areas? MARK YES OR NO ON EACH
ROW.
Yes

a. Reading/language arts
b. Mathematics
c. Science
d. Social studies

D2.

How long has this child been in your reading/language arts class this school year until now? MARK
ONE RESPONSE.
Entire school year until now
More than one semester but less than the entire school year until now
More than one quarter but less than one semester
Less than one quarter of the school year

D3.

Please indicate the total number of times this child has been absent from your reading/language
arts class during the current school year. MARK ONE RESPONSE.
No absences
1 to 4 absences
5 to 7 absences
8 to 10 absences
11 to 19 absences
20 or more absences

D4.

Does this child receive (or has he/she received during this school year) instruction in any of the
following types of programs in your school? MARK YES OR NO ON EACH ROW.
Yes
a. Individual tutoring or remedial program in reading/language arts
b. Gifted and talented program in reading/language arts
c. Gifted and talented program with no specific content focus

Draft

D5.

Is English this child's native language? MARK ONE RESPONSE.
Yes (SKIP TO Q D11)
No
Don't know

D6.

Does this child participate in an instructional program designed to teach English language skills
to children with limited English proficiency? MARK ONE RESPONSE.
Yes
No (SKIP TO Q D11)

D7.

Would you say the instruction this child receives is primarily… MARK ONE RESPONSE.
EXAMPLES OF THE PROGRAMS INCLUDED IN EACH CATEGORY ARE PROVIDED BELOW.
SEE PAGE 4 FOR DEFINITIONS OF THESE EXAMPLES.
Programs that focus on developing students' literacy in two languages. For example:






Two-way immersion program or two-way bilingual program
Developmental bilingual program, late exit transitional program, or
maintenance bilingual education program
Transitional program, early exit bilingual program, or early exit transitional program
Heritage language program or indigenous language program

Programs that focus on developing students' literacy solely in English. For example:






Sheltered English instruction or content-based English as a Second
Language (ESL) program
Structured English Immersion (SEI)
Pull-out English as a Second Language (ESL) or English Language Development (ELD)
Push-in ESL program

Other program(s) (PLEASE SPECIFY)

No specialized language program is provided to this child. (SKIP TO Q D10)

Draft

D8.

How often does this child usually receive specialized language instruction of the following program
types? MARK ONE RESPONSE ON EACH ROW.

Never

Less
than
once
a week

1 day
a week

2 days
a week

3 days
a week

4 days
a week

5 days
a week

a. Program that focuses on
developing students' literacy in
two languages
b. Program that focuses on
developing students' literacy
solely in English
c. Other program

D9.

On the days when this child receives specialized language instruction, for how much time does he/she
receive instruction of the following program types? MARK ONE RESPONSE ON EACH ROW.
Not
Less
applicable/ than ½
never
hour

½ hour
to less 1 to less
than 1 than 1 ½
hours
hour

1 ½ to
less
than 2
hours

2 to less
than 2 ½
hours

2 ½ to
less
than 3
hours

a. Program that focuses on
developing students'
literacy in two languages
b. Program that focuses on
developing students'
literacy solely in English
c. Other program

D10.

During this school year, how often is this child's reading instruction provided in his/her native
language? MARK ONE RESPONSE.
None of the time
Less than half of the time
Half of the time
More than half of the time
Almost all the time

3 hours
or more

Draft

D11.

Does this child have an IEP on record with the school? MARK ONE RESPONSE.
Yes
No

D12.

Does this child receive instruction in any of the following types of programs in your school? MARK
YES OR NO ON EACH ROW.
Yes

a. Speech-language therapy for children with speech or language
disorders/impairments
b. Special education services, not including speech therapy, whether
provided in the classroom or in a pull-out setting
D13.

Does this child receive special accommodations (for example, for a disability or limited
English proficiency) to participate in the school's testing or assessment program? MARK
ONE RESPONSE.
Yes
No
Don't know
Child does not participate in the school's testing or assessment program
There is no testing or assessment program at this grade level

D14.

Overall, how would you rate this child's academic skills in each of the following areas, based on
curriculum standards for his/her current grade level? MARK ONE RESPONSE ON EACH ROW.
Below
grade level

About on
grade level

Above
grade level

a. Reading
b. Writing
c. Oral language
d. Social studies
D15.

How often does this child work to the best of her/his ability in READING AND LANGUAGE ARTS?
MARK ONE RESPONSE.
Never
Seldom
Usually
Always

Draft

D16.

How many instructional groups based on achievement or ability levels in READING do you currently
have in this child's class? MARK ONE RESPONSE.
I do not use instructional groups for reading (SKIP TO Q D18)
Two
Three
Four
Five or more

D17.

In which reading instructional group is this child currently placed? USE "1" FOR THE HIGHEST
INSTRUCTIONAL GROUP. WRITE THE NUMBER OF THE CHILD'S INSTRUCTIONAL GROUP BELOW.
Instructional Group

D18.

During this school year, have this child's parents/guardians participated in the following
activities? MARK ONE RESPONSE ON EACH ROW.
Not
applicable/
not offered
Yes
No
a. Attended regularly-scheduled conferences at
your school
b. Attended parent/teacher informal meetings that
you initiated to talk about the child's progress
c. Returned your telephone calls or e-mails
d. Initiated contact with you
e. Volunteered to help in your classroom or school

D19.

How involved at the school would you say this child's parents/guardians are? MARK ONE
RESPONSE.
Not involved at all
Somewhat involved
Very involved
Don't know

Draft

D20.

During this school year, besides regular teacher conferences, have you communicated with
this child's parents/guardians? MARK ONE RESPONSE.
Yes
No (SKIP TO Q D22)

D21.

Was the purpose of the communication with this child's parents/guardians to discuss ...
MARK YES OR NO ON EACH ROW.
Yes

a. Behavior problems the child is having in school?
b. Any problems the child is having with school work?
c. Anything the child is doing particularly
well in or better in at school?

D22.

Date Questionnaire Completed:

2 0 1 6
MONTH

DAY

YEAR

If there is a red dot next to the child's name on the cover of this questionnaire, please continue with
Part 2.
If there is no red dot next to the child's name on the cover, you are finished with the questionnaire.
Thank you for your cooperation!

Draft

PART 2:
To be completed only if there is a red dot next to the child's name on the cover
of this questionnaire.
If there is no red dot next to the child's name on the cover, you are finished with the questionnaire.
Thank you for your cooperation!

Draft

SECTION E. READING AND LANGUAGE ARTS INSTRUCTION
Please answer the following questions for the reading class in which the child identified on the cover of this
questionnaire receives reading and language arts instruction.
E1.

From the first day of school until today, please indicate on how many days you have covered each of
the following READING AND LANGUAGE ARTS skills and concepts in this child's class. Please include
the time during which you provide direct instruction as well as the time you spend supervising
students as they work.
Please focus on the skill areas that are shown in bold text. (The unbolded examples are only a sample
of things you may do or cover under this skill area.) MARK ONE RESPONSE ON EACH ROW.

Literature

Not yet
taught
or not
taught
in this
grade

a. Understanding key ideas and details, for
example, identifying the main idea or theme;
summarizing; comparing characters and settings;
using details and quotations from the text to
support understanding of the passage; etc.
b. Understanding craft and structure, for
example, understanding metaphors and
similes; explaining the structure of a story,
drama, or poem; describing the influence of
the narrator's point of view; etc.
c. Integrating knowledge and ideas, for example,
analyzing how visual or multi-media presentation
of a text contributes to the meaning or tone of
the text; comparing treatment of similar themes
in stories and myths; etc.

Informational Text
d. Understanding key ideas and details, for example,
quoting accurately from a text; summarizing main
ideas from a text; etc.
e. Understanding craft and structure, for example,
comparing the structure of events, concepts, or
information in two or more texts; analyzing
different accounts of the same event; etc.
f. Integrating knowledge and ideas, for example,
using information from multiple print or digital
sources to locate an answer; explaining how the
author uses evidence to support a point in the text;
integrating information from several texts to write
or speak knowledgeably about the topic; etc.

On
1-10
days

On
11-20
days

On
21-40
days

On
41-80
days

On more
than 80
days

Draft

E1.

(continued) From the first day of school until today, please indicate on how many days you have
covered each of the following READING AND LANGUAGE ARTS skills and concepts in this child's
class. Please include the time during which you provide direct instruction as well as the time you
spend supervising students as they work.
Please focus on the skill areas that are shown in bold text. (The unbolded examples are only a sample
of things you may do or cover under this skill area.) MARK ONE RESPONSE ON EACH ROW.

Writing and Language

Not yet
taught
or not
taught
in this
grade

g. Writing narratives, opinion pieces, and
informational text with facts and details
h. Developing and strengthening writing by
planning, drafting, revising, and editing
i. Building vocabulary, for example, studying
words and their meanings in text; learning
about roots, prefixes, and suffixes
j. Understanding conventions of standard
English, for example, explaining the functions of
conjunctions and prepositions; using verb tense
to convey various times; using punctuation to
separate items in a series; etc.

On
1-10
days

On
11-20
days

On
21-40
days

On
41-80
days

On more
than 80
days

Draft

E2.

How often do the children in this class engage in the following reading and language arts activities?
MARK ONE RESPONSE ON EACH ROW.
Almost
every
day
a. Read silently
b. Read books they have chosen themselves
c. Make oral presentations about what they have read
d. Do a group activity or project about what they
have read
e. Discuss different interpretations of what they
have read
f.

Look up vocabulary words and write
definitions

g. Demonstrate understanding of words by relating
them to their opposites (antonyms) and to words
with similar meanings (synonyms)
h. When given specific questions, write responses
that are at least 3 to 4 sentences long
i.

Cite evidence from literary or informational texts
(books and/or digital sources) in their writing

Spend extended time writing and revising text
that they have written

k. Edit their classmates' writing

Once or
twice a
week

Once or
twice a
month

Less than
once a
month or
never

Draft

SECTION F. CLASSROOM AND STUDENT CHARACTERISTICS
Please answer the following questions for the reading class in which the child identified on the cover of
this questionnaire receives reading and language arts instruction.
F1.

As of today's date, how many children …
WRITE NUMBER IN BOX. IF THERE ARE NO CHILDREN IN A PARTICULAR CATEGORY, WRITE "0."
Number of
children
a. Are currently enrolled in this class?
b. Are boys?
c. Are girls?

F2.

What grade levels are included in this class? MARK ALL THAT APPLY.
a. 3rd grade or lower
b. 4th grade
c. 5th grade
d. 6th grade
e. 7th grade or higher

F3.

How many of the children in this class are repeating their grade this year? WRITE NUMBER IN BOX.
IF NONE, WRITE "0."
Number of children repeating their grade

Draft

F4.

How many children in this class ...
WRITE NUMBER IN BOX. IF NONE, WRITE "0."
Number of
children
a. Are classified as Gifted and Talented?
b. Are participating in a Gifted and Talented program?

F5.

How many children in this class are absent on an average day? WRITE NUMBER IN BOX. IF NONE,
WRITE "0."
Number of children absent on an average day

F6.

How many children in this class are below grade level, about on grade level, or above grade level
in their English reading skills and in social studies?
WRITE NUMBER IN BOX. IF NONE, WRITE "0."
I do not teach
this subject

Below
grade level

About on
grade level

Above
grade level

a. English reading skills?
b. Social studies?

F7.

At this point in the school year, how would you rate the behavior of the children in this class?
MARK ONE RESPONSE.
Group misbehaves very frequently and is almost always difficult to handle.
Group misbehaves frequently and is often difficult to handle.
Group misbehaves occasionally.
Group behaves well.
Group behaves exceptionally well.

Draft

F8.

Approximately what percentage of the students in this class demonstrate the following problems?
MARK ONE RESPONSE ON EACH ROW.
0%

1-10%

11-25%

26-50%

51-75% 76-100%

a. Have difficulty paying attention in class
b. Lack self-control (disruptive behavior)
c. Are rejected by peers
d. Do not accept authority
Source: Abry, T., Swanson, J., and Fabes, R. A. (2012). The Classroom Environment Student Difficulties Scale. Arizona State University,
Unpublished measure. Adapted with permission.

F9.

How many children in this class have a diagnosed disability? WRITE NUMBER IN BOX. IF NONE,
WRITE "0."
Number of children diagnosed with a disability

F10.

Do you have any children who are English language learners in this class? (English language
learners are children whose native language is one other than English and whose skills in
listening, speaking, reading, or writing English are such that they have difficulty understanding
school instruction in English.) MARK ONE RESPONSE.
Yes
No (SKIP TO Q G1)

F11.

How many English language learners (ELLs) do you have in this class? WRITE NUMBER IN BOX. IF
NONE, WRITE "0."
Number of ELL children

Draft

SECTION G. CLASSROOM INSTRUCTION AND EVALUATION
Please answer the following questions for the reading class in which the child identified on the cover of
this questionnaire receives reading and language arts instruction.
G1.

In a typical day, how much time do children in this reading and language arts class spend in the
following activities? MARK ONE RESPONSE ON EACH ROW. DO NOT INCLUDE LUNCH OR RECESS
BREAKS.
Longer
No
1-15
16-30
31-45
than 45
time
minutes
minutes
minutes
minutes
a. Working independently
b. Working on individual tasks under
teacher direction
c. Working with peers under teacher
direction
d. Working in small groups with
teacher
e. Teacher lecture with large group
and/or large group discussion led
by teacher

G2.

How often do the children in this reading and language arts class go to the school library or
media center? MARK ONE RESPONSE.
No library or media center in this school
Once a month or less
Two or three times a month
Once or twice a week
Three or four times a week
Daily

Draft

G3.

In this class, how frequently do you or your students use computers or the following electronic
devices for instructional purposes in reading and language arts? Please include any desktop,
laptop, or other computer-type devices. MARK ONE RESPONSE ON EACH ROW.
Not
available

Never

Rarely

Sometimes

Often

a. Desktop or laptop computer or
other computer-type device (for
example, iPad/other tablet,
eReader such as Kindle or Nook)
b. Cell phone/smartphone (for
example, iPhone)
c. Interactive whiteboard (for
example, SMART Board,
Activboard)
d. Document camera or document
projector (for example, ELMO,
HoverCam)
e. LCD or DLP projector
f.

Digital camera (still or video)

g. CD player, MP3 player/iPod,
cassette/tape player
h. DVD player, VCR, or video
streaming device (for example,
Roku)
i.

Student response system (for
example, clickers, responders,
ActiVote, ActivExpression)

k. Microphone or classroom audio
sound system (for example,
TopCat, Redcat)

G4.

In an average week, how many days a week is reading and language arts homework assigned in
this class? Please count homework assigned over the weekend as one day. MARK ONE RESPONSE.
0 days (SKIP TO Q G6)
1 day
2 days
3 days
4 days
5 days

Draft

G5.

On days when homework is assigned, how much time do you expect children in this class to spend
on homework in reading and language arts? MARK ONE RESPONSE.
1 to 10 minutes
11 to 20 minutes
21 to 30 minutes
More than 30 minutes

G6.

In this class, how often do you use a formal assessment in READING for the following purposes?
MARK ONE RESPONSE ON EACH ROW.

Never

Once a
year

a. To evaluate how well each
student is responding to the
core curriculum provided in
the general education
classroom
b. To monitor each student's
progress on specific skills
over the school year
c. To identify the deficits in
specific skills of struggling
students
d. To monitor the progress of
students who fall below
benchmark levels
e. To determine whether
students need placement in a
more or less intensive level of
instruction

3 to 4
2 times times a
a year
year

5 to 8
times a
year

1 to 2
times a
month

1 to 2
times a
week

Draft

SECTION H. STAFF ACTIVITIES
H1.

Did you participate in any professional development* within the last 12 months? MARK ONE
RESPONSE.
Yes (GO TO Q H2)
No (YOU ARE FINISHED WITH THE QUESTIONNAIRE)
* Professional development may include continuing formal education; courses, conferences,
workshops, or in-service training; staff meetings that include staff development activities; and
receiving coaching or mentoring.

H2.

How often did you participate in professional development activities covering the following topics
in the last 12 months? MARK ONE RESPONSE ON EACH ROW.

Never

Once

2 times

3 to 4
times

a. How to use assessment data to identify
students who are struggling or at risk of
failure in READING
b. How to use and apply assessment data
to guide READING instruction
c. How to implement the READING
curriculum

THANK YOU FOR YOUR COOPERATION!

More
than 4
times

Draft

For Office Use Only
Comp
Ref

Draft

Spring 2016
Mathematics
Teacher Questionnaire
Child Level
Prepared for the U.S. Department of Education
National Center for Education Statistics by:
Westat
Rockville, Maryland
Use a black or blue ball point pen to complete this questionnaire.

S_ID
C_ID

T_ID

Link_ID

Draft

THANK YOU VERY MUCH FOR YOUR HELP.

Draft

Incorrect Marks:
Light and thin, outside the box, thick or scrawled.

How to Change an Answer:
Completely black out the box of the incorrect answer and mark an “X” in the box next to the
correct answer.

Write words like this:

John Smith

0, and do not

Draft

PART 1:
Please answer the questions in Part 1 about the child identified on the
cover of this questionnaire.

Draft

SECTION A. STUDENT INFORMATION
Please answer the following questions about the child identified on the cover of this questionnaire.
A1.

Are you this child's primary teacher in the following subject areas? MARK YES OR NO ON EACH
ROW.
Yes

a. Reading/language arts
b. Mathematics
c. Science
d. Social studies

A2.

How long has this child been in your math class this school year until now? MARK ONE RESPONSE.
Entire school year until now
More than one semester but less than the entire school year until now
More than one quarter but less than one semester
Less than one quarter of the school year

A3.

Please indicate the total number of times this child has been absent from your math class during
the current school year. MARK ONE RESPONSE.
No absences
1 to 4 absences
5 to 7 absences
8 to 10 absences
11 to 19 absences
20 or more absences

A4.

Does this child receive (or has he/she received during this school year) instruction in any of the
following types of programs in your school? MARK YES OR NO ON EACH ROW.
Yes
a. Individual tutoring or remedial program in mathematics
b. Gifted and talented program in mathematics

Draft

A5.

Is English this child's native language? MARK ONE RESPONSE.
Yes (SKIP TO Q A7)
No
Don't know

A6.

During this school year, how often is this child's math instruction provided in his/her native
language? MARK ONE RESPONSE.
None of the time
Less than half of the time
Half of the time
More than half of the time
Almost all the time

A7.

Overall, how would you rate this child's academic skills in MATH, based on curriculum standards for
his/her current grade level? MARK ONE RESPONSE.
Below grade level
About on grade level
Above grade level

A8.

How often does this child work to the best of her/his ability in MATH? MARK ONE RESPONSE.
Never
Seldom
Usually
Always

A9.

How many instructional groups based on achievement or ability levels in MATHEMATICS do
you currently have in this child's class? MARK ONE RESPONSE.
I do not use instructional groups for mathematics
Two
Three
Four
Five or more

(SKIP TO Q A11)

Draft

A10.

In which mathematics instructional group is this child currently placed? USE "1" FOR THE HIGHEST
INSTRUCTIONAL GROUP. WRITE THE NUMBER OF THE CHILD'S INSTRUCTIONAL GROUP BELOW.
Instructional Group

A11.

A12.

During this school year, besides regular teacher conferences, have you communicated with
this child's parents/guardians? MARK ONE RESPONSE.
Yes
No (SKIP TO Q A14)

A13.

Was the purpose of the communication with this child's parents/guardians to discuss ...
MARK YES OR NO ON EACH ROW.
Yes
No
a. Behavior problems the child is having in school?
b. Any problems the child is having with school work?
c. Anything the child is doing particularly
well in or better in at school?

A14.

Date Questionnaire Completed:

2 0 1 6
MONTH

DAY

YEAR

If there is a red dot next to the child's name on the cover of this questionnaire, please
continue with Part 2.
If there is no red dot next to the child's name on the cover, you are finished with the
questionnaire. Thank you for your cooperation!
8

Draft

SECTION B. MATHEMATICS INSTRUCTION
Please answer the following questions for the math class in which the child on the cover of this questionnaire
receives math instruction.
B1.

From the first day of school until today, please indicate on how many days you have covered each of
the following MATHEMATICS skills and concepts in this child's class. Please include the time during
which you provide direct instruction as well as the time you spend supervising students as they work.
Please focus on the skill areas that are shown in bold text. (The unbolded examples are only a sample
of things you may do or cover under this skill area.) MARK ONE RESPONSE ON EACH ROW.
Not yet
taught
or not
taught
in this
grade

a. Using algebraic thinking, for example, using parentheses
in numerical expressions; writing and interpreting simple
numerical expressions; generating and graphing numerical
patterns; etc.
b. Understanding place value, for example, understanding
the value of a digit in one place as compared to an adjacent
place; using whole number exponents to denote powers of
10; reading, writing, and comparing decimals to
thousandths; rounding decimals; etc.
c. Adding, subtracting, multiplying, and dividing
multiple-digit whole numbers and decimals to hundredths
d. Understanding fractions, for example, adding and
subtracting fractions with unlike denominators;
understanding the relationship between decimals and
fractions; solving real world problems involving multiplying
and dividing fractions by whole numbers; etc.
e. Using concepts of geometric measurement, for example,
converting among different measurement units; making
plots or graphs to display fractions of a unit; understanding
and using units of volume; solving volume problems using
multiplication and addition; etc.
f. Representing and interpreting data, for example, making
line plots or other visuals to display fractions of a unit; using
operations on fractions to answer questions about a line plot;
etc.
g. Understanding geometric concepts, for example, using
axes (perpendicular lines) to define a coordinate system;
classifying two-dimensional figures such as squares and
rectangles; etc.

On
1-10
days

On
11-20
days

On
21-40
days

On On more
41-80 than 80
days
days

Draft

B2.

How often do the children in this class engage in the following mathematics activities? MARK ONE
RESPONSE ON EACH ROW.
Almost
every
day
a. Solve mathematics problems from textbooks or
worksheets
b. Solve mathematics problems from the
blackboard, whiteboard/SMART Board, or
projector
c. Solve mathematics problems in small groups or
with a partner
d. Work with measuring instruments (for example,
rulers, compasses, protractors)
e. Work with manipulatives (for example, geometric
shapes, fraction bars)
f.

Use a calculator

g. Take mathematics tests/quizzes
h. Write a few sentences about how to solve a
mathematics problem
i.

Discuss solutions to mathematics problems with
other students

Work on and discuss mathematics problems that
reflect real-life situations

k. Use a computer or tablet (for example, iPad, Surface)
for math (beyond using the device's calculator)
l.

Interpret visual representations (for example,
diagrams, graphs, tables, models)

m. Create visual representations (for example,
diagrams, graphs, tables, models)

Once or
twice a
week

Once or
twice a
month

Less than
once a
month or
never

Draft

SECTION C. CLASSROOM AND STUDENT CHARACTERISTICS
Please answer the following questions for the math class in which the child identified on the cover of this
questionnaire receives math instruction.
C1.

C2.

What grade levels are included in this class? MARK ALL THAT APPLY.
a. 3rd grade or lower
b. 4th grade
c. 5th grade
d. 6th grade
e. 7th grade or higher

C3.

How many of the children in this class are repeating their grade this year? WRITE NUMBER IN BOX.
IF NONE, WRITE "0."
Number of children repeating their grade

Draft

C4.

How many children in this class ...
WRITE NUMBER IN BOX. IF NONE, WRITE "0."
Number of
children
a. Are classified as Gifted and Talented?
b. Are participating in a Gifted and Talented program?

C5.

How many children in this class are absent on an average day? WRITE NUMBER IN BOX. IF NONE,
WRITE "0."
Number of children absent on an average day

C6.

How many children in this class are below grade level, about on grade level, or above grade level
in mathematics skills?
WRITE NUMBER IN BOX. IF NONE, WRITE "0."
Number of children below grade level
Number of children about on grade level
Number of children above grade level

C7.

Draft

C8.

Approximately what percentage of the students in this class demonstrate the following problems?
MARK ONE RESPONSE ON EACH ROW.
0%

1-10%

11-25%

26-50%

51-75% 76-100%

C9.

How many children in this class have a diagnosed disability? WRITE NUMBER IN BOX. IF NONE,
WRITE "0."
Number of children diagnosed with a disability

C10.

C11.

How many English language learners (ELLs) do you have in this class? WRITE NUMBER IN BOX. IF
NONE, WRITE "0."
Number of ELL children

Draft

SECTION D. CLASSROOM INSTRUCTION AND EVALUATION
Please answer the following questions for the math class in which the child identified on the cover of this
questionnaire receives math instruction.
D1.

In a typical day, how much time do children in this math class spend in the following activities?
MARK ONE RESPONSE ON EACH ROW. DO NOT INCLUDE LUNCH OR RECESS BREAKS.
No
time
a. Working independently
b. Working on individual tasks under
teacher direction
c. Working with peers under teacher
direction
d. Working in small groups with
teacher
e. Teacher lecture with large group
and/or large group discussion led
by teacher

1-15
minutes

16-30
minutes

31-45
minutes

Longer
than 45
minutes

Draft

D2.

In this class, how frequently do you or your students use computers or the following electronic
devices for instructional purposes in math? Please include any desktop, laptop, or other
computer-type devices. MARK ONE RESPONSE ON EACH ROW.
Not
available

Never

Rarely

Sometimes

Often

Digital camera (still or video)

g. CD player, MP3 player/iPod,
cassette/tape player
h. DVD player, VCR, or video
streaming device (for example,
Roku)
i.

Student response system (for
example, clickers, responders,
ActiVote, ActivExpression)

k. Microphone or classroom audio
sound system (for example,
TopCat, Redcat)

D3.

In an average week, how many days a week is math homework assigned in this math class? Please
count homework assigned over the weekend as one day. MARK ONE RESPONSE.
0 days (SKIP TO Q D5)
1 day
2 days
3 days
4 days
5 days

Draft

D4.

On days when homework is assigned, how much time do you expect children in this class to spend
on homework in math? MARK ONE RESPONSE.
1 to 10 minutes
11 to 20 minutes
21 to 30 minutes
More than 30 minutes

D5.

In this class, how often do you use a formal assessment in MATH for the following purposes?
MARK ONE RESPONSE ON EACH ROW.

Never

Once a
year

3 to 4
2 times times a
a year
year

5 to 8
times a
year

1 to 2
times a
month

1 to 2
times a
week

Draft

SECTION E. STAFF ACTIVITIES
E1.

Did you participate in any professional development* within the last 12 months? MARK ONE
RESPONSE.
Yes (GO TO Q E2)
No (YOU ARE FINISHED WITH THE QUESTIONNAIRE)
* Professional development may include continuing formal education; courses, conferences,
workshops, or in-service training; staff meetings that include staff development activities; and
receiving coaching or mentoring.

E2.

How often did you participate in professional development activities covering the following topics
in the last 12 months? MARK ONE RESPONSE ON EACH ROW.

Never

Once

2 times

3 to 4
times

a. How to use assessment data to identify
students who are struggling or at risk of
b.
failure in MATH
b. How to use and apply assessment data
to guide MATH instruction
c. How to implement the MATH
curriculum

THANK YOU FOR YOUR COOPERATION!

More
than 4
times

Draft

For Office Use Only
Comp
Ref

Draft

Spring 2016
Science
Teacher Questionnaire
Child Level
Prepared for the U.S. Department of Education
National Center for Education Statistics by:
Westat
Rockville, Maryland
Use a black or blue ball point pen to complete this questionnaire.

S_ID
C_ID

T_ID

Link_ID

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 voluntary survey is
1850-0750. Approval expires XX/XX/XXXX. The time required to complete this
survey is estimated to average 12 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed,
and complete and review the survey. If you have any comments concerning
the accuracy of the time estimate or suggestions for improving this survey, or
any comments or concerns regarding the status of your individual submission
of this survey, please write to: Early Childhood Longitudinal Study, National
Center for Education Statistics, 1990 K Street, N.W., Washington, D.C. 200065574.

Draft

THANK YOU VERY MUCH FOR YOUR HELP.

Draft

Incorrect Marks:
Light and thin, outside the box, thick or scrawled.

How to Change an Answer:
Completely black out the box of the incorrect answer and mark an “X” in the box next to the
correct answer.

Write words like this:

John Smith

0, and do not

Draft

PART 1:
Please answer the questions in Part 1 about the child identified on the
cover of this questionnaire.

Draft

SECTION A. STUDENT INFORMATION
Please answer the following questions about the child identified on the cover of this questionnaire.
A1.

Are you this child's primary teacher in the following subject areas? MARK YES OR NO ON EACH
ROW.
Yes

a. Reading/language arts
b. Mathematics
c. Science
d. Social studies

A2.

How long has this child been in your science class this school year until now? MARK ONE RESPONSE.
Entire school year until now
More than one semester but less than the entire school year until now
More than one quarter but less than one semester
Less than one quarter of the school year

A3.

Please indicate the total number of times this child has been absent from your science class during
the current school year. MARK ONE RESPONSE.
No absences
1 to 4 absences
5 to 7 absences
8 to 10 absences
11 to 19 absences
20 or more absences

A4.

Is English this child's native language? MARK ONE RESPONSE.
Yes (SKIP TO Q A6)
No
Don't know

Draft

A5.

During this school year, how often is this child's science instruction provided in his/her native
language? MARK ONE RESPONSE.
None of the time
Less than half of the time
Half of the time
More than half of the time
Almost all the time

A6.

Overall, how would you rate this child's academic skills in SCIENCE, based on curriculum standards
for his/her current grade level? MARK ONE RESPONSE.
Below grade level
About on grade level
Above grade level

A7.

How often does this child work to the best of her/his ability in SCIENCE? MARK ONE RESPONSE.
Never
Seldom
Usually
Always

A8.

Draft

A9.

During this school year, besides regular teacher conferences, have you communicated with
this child's parents/guardians? MARK ONE RESPONSE.
Yes
No (SKIP TO Q A11)

A10.

A11.

Date Questionnaire Completed:

2 0 1 6
MONTH

DAY

YEAR

If there is a red dot next to the child's name on the cover of this questionnaire, please
continue with Part 2.
If there is no red dot next to the child's name on the cover, you are finished with the
questionnaire. Thank you for your cooperation!

Draft

SECTION B. SCIENCE INSTRUCTION

Please answer the following questions for the science class in which the child identified on the cover of this
questionnaire receives science instruction.
B1.

From the first day of school until today, please indicate on how many days you have covered each of
the following SCIENCE skills and concepts in this child's class. Please include the time during which
you provide direct instruction as well as the time you spend supervising students as they work.
Please focus on the skill areas that are shown in bold text. (The unbolded examples are only a sample
of things you may do or cover under this skill area.) MARK ONE RESPONSE ON EACH ROW.

Fields of Science

Not yet
taught
or not
taught
in this
grade

a. Physical science, for example, understanding
matter, chemical reactions, gravity, energy, etc.
b. Life science, for example, learning about
organisms, life cycles, food chains,
ecosystems, etc.
c. Earth science, for example, learning about the
solar system; interactions of the geosphere,
hydrosphere, atmosphere, and biosphere;
effects of human activity on Earth's resources
and environments; etc.

Scientific Method
d. Conceptual modeling, for example, developing
and using models to describe events,
phenomena, etc.
e. Scientific testing, for example, planning and
conducting investigations, observing and
measuring using appropriate tools and fair tests
to generate data, etc.
f. Analysis and conclusions, for example,
analyzing the results of a scientific
investigation and determining whether the
results support the initial prediction, etc.

Science, Engineering, and Technology
g. Interdependence of science, technology,
and engineering, for example, exploring how
scientific discoveries lead to the development
of new technologies, new technologies lead to
new scientific discoveries, etc.
h. Engineering concepts, for example, identifying
a simple design problem that can be solved
through the development of an object, tool,
process, or system; etc.

On
1-10
days

On
11-20
days

On
21-40
days

On
41-80
days

On more
than 80
days

Draft

B2.

How often do the children in this class engage in the following science activities? MARK ONE
RESPONSE ON EACH ROW.
Almost
every
day
a. Read a science textbook or e-book
b. Discuss science in the news
c. Generate and test hypotheses
d. Work with other children on a science activity or
project
e. Use hands-on science equipment (for example,
magnifying glass, scales, thermometers,
microscopes, dissecting tools, etc.)
f.

Use "virtual" science equipment, that is, use
computer-based interactive renderings of science
equipment

g. Engage in hands-on activities or investigations
in science
h. Engage in "virtual" activities or investigations in
science, that is, using computer-based tools for
the activities or investigations
i.

Talk about measurements and results from
children’s hands-on activities

Talk about measurements and results from "virtual"
activities

k. Prepare a written science report
l.

Take a science test or quiz

m. Use library or media center resources for science

Once or
twice a
week

Once or
twice a
month

Less than
once a
month or
never

Draft

SECTION C. CLASSROOM AND STUDENT CHARACTERISTICS
Please answer the following questions for the science class in which the child identified on the cover of
this questionnaire receives science instruction.
C1.

C2.

What grade levels are included in this class? MARK ALL THAT APPLY.
a. 3rd grade or lower
b. 4th grade
c. 5th grade
d. 6th grade
e. 7th grade or higher

C3.

How many of the children in this class are repeating their grade this year? WRITE NUMBER IN BOX.
IF NONE, WRITE "0."
Number of children repeating their grade

Draft

C4.

How many children in this class ...
WRITE NUMBER IN BOX. IF NONE, WRITE "0."
Number of
children
a. Are classified as Gifted and Talented?
b. Are participating in a Gifted and Talented program?

C5.

How many children in this class are absent on an average day? WRITE NUMBER IN BOX. IF NONE,
WRITE "0."
Number of children absent on an average day

C6.

How many children in this class are below grade level, about on grade level, or above grade level
in science?
WRITE NUMBER IN BOX. IF NONE, WRITE "0."
Number of children below grade level
Number of children about on grade level
Number of children above grade level

C7.

Draft

C8.

Approximately what percentage of the students in this class demonstrate the following problems?
MARK ONE RESPONSE ON EACH ROW.
0%

1-10%

11-25%

26-50%

51-75% 76-100%

C9.

How many children in this class have a diagnosed disability? WRITE NUMBER IN BOX. IF NONE,
WRITE "0."
Number of children diagnosed with a disability

C10.

C11.

How many English language learners (ELLs) do you have in this class? WRITE NUMBER IN BOX. IF
NONE, WRITE "0."
Number of ELL children

Draft

SECTION D. CLASSROOM INSTRUCTION AND EVALUATION
Please answer the following questions for the science class in which the child identified on the cover of this
questionnaire receives science instruction.
D1.

In a typical day, how much time do children in this science class spend in the following activities?
MARK ONE RESPONSE ON EACH ROW. DO NOT INCLUDE LUNCH OR RECESS BREAKS.
No
time
a. Working independently
b. Working on individual tasks under
teacher direction
c. Working with peers under teacher
direction
d. Working in small groups with
teacher
e. Teacher lecture with large group
and/or large group discussion led
by teacher

1-15
minutes

16-30
minutes

31-45
minutes

Longer
than 45
minutes

Draft

D2.

In this class, how frequently do you or your students use computers or the following electronic
devices for instructional purposes in science? Please include any desktop, laptop, or other
computer-type devices. MARK ONE RESPONSE ON EACH ROW.
Not
available

Never

Rarely

Sometimes

Often

Digital camera (still or video)

g. CD player, MP3 player/iPod,
cassette/tape player
h. DVD player, VCR, or video
streaming device (for example,
Roku)
i.

Student response system (for
example, clickers, responders,
ActiVote, ActivExpression)

k. Microphone or classroom audio
sound system (for example,
TopCat, Redcat)

D3.

In an average week, how many days a week is science homework assigned in this class? Please
count homework assigned over the weekend as one day. MARK ONE RESPONSE.
0 days (SKIP TO Q D5)
1 day
2 days
3 days
4 days
5 days

Draft

D4.

On days when homework is assigned, how much time do you expect children in this class to spend
on homework in science? MARK ONE RESPONSE.
1 to 10 minutes
11 to 20 minutes
21 to 30 minutes
More than 30 minutes

D5.

In this class, how often do you use a formal assessment in SCIENCE for the following purposes?
MARK ONE RESPONSE ON EACH ROW.

Never

Once a
year

3 to 4
2 times times a
a year
year

5 to 8
times a
year

1 to 2
times a
month

1 to 2
times a
week

Draft

SECTION E. STAFF ACTIVITIES
E1.

E2.

How often did you participate in professional development activities covering the following topics
in the last 12 months? MARK ONE RESPONSE ON EACH ROW.

Never

Once

2 times

3 to 4
times

a. How to use assessment data to identify
students who are struggling or at risk of
failure in SCIENCE
b. How to use and apply assessment data
to guide SCIENCE instruction
c. How to implement the SCIENCE
curriculum

THANK YOU FOR YOUR COOPERATION!

More
than 4
times

Draft

For Office Use Only
Comp
Ref

Draft

File Type	application/pdf
File Modified	2015-07-01
File Created	2015-06-25