Form 0 Appendix D

EHS 5TH GRADE FOLLOW-UP STUDY
TEACHER QUESTIONNAIRE

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.1

SECTION 1
CHILD’S CLASSROOM

A11.

What grade is the child in?
_______
¨ Not enrolled in a grade
¨ Refused
¨ Don’t know

A2

In which subject(s) do you instruct the child?

MARK ALL THAT APPLY
¨ Language Arts
¨ Math
¨ Social Studies
¨ Science
¨ Other (Specify: _________________)
A2.1

Has the child been in your class since the beginning of this school year?
¨ Yes
¨ No (Number of months child was in your class since the beginning of the school year: _______)

A3.

Including the child, what is the number of students you teach in the child’s class?
_________Students

A4.

Including you, how many adults (teachers and aides) are usually in the child’s class?
__________Adults

A9.

In a typical week, how many paid aides usually assist in the child’s class by working directly with
children on instructional tasks?
_______ Number of regular aides
_______ Number of special education aides for whole class
_______ Number of special education aides assigned to one single child
_______ Number of ESL or bilingual education aides

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.2

A10.

What is the highest level of education completed for the paid aide who spends the most time in
the child’s class?

MARK ONLY ONE

¨ Less than high school
¨ High school diploma or GED
¨ Associate’s degree
¨ Bachelor’s degree or above
¨ Don’t know
¨ No paid aides assist in my classroom

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.3

SECTION 2
CHILD CHARACTERISTICS

Please rate the degree the child displays the following characteristics.
G1A

Pays attention well.
¨ Never
¨ Sometimes
¨ Often
¨ Very often

G1B

Persists in completing tasks.
¨ Never
¨ Sometimes
¨ Often
¨ Very often

G1C Shows eagerness to learn new things.
¨ Never
¨ Sometimes
¨ Often
¨ Very often
G1D Works independently.
¨ Never
¨ Sometimes
¨ Often
¨ Very often
G1F

Keeps belongings organized.
¨ Never
¨ Sometimes
¨ Often
¨ Very often

H1A

Respects the property rights of others
¨ Never
¨ Sometimes
¨ Often
¨ Very often

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.4

H1B

Accepts peers’ ideas for group activities
¨ Never
¨ Sometimes
¨ Often
¨ Very often

H1C

Responds appropriately to peer pressure
¨ Never
¨ Sometimes
¨ Often
¨ Very often

H1D

Forms and maintains friendships
¨ Never
¨ Sometimes
¨ Often
¨ Very often

H1E

Gets along with people who are different
¨ Never
¨ Sometimes
¨ Often
¨ Very often

H1F

Comforts or helps other children
¨ Never
¨ Sometimes
¨ Often
¨ Very often

H1G

Is sensitive to feelings of others
¨ Never
¨ Sometimes
¨ Often
¨ Very often

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.5

Please rate the degree the child displays the following characteristics.
E1A.

Uses free time in an acceptable way
¨ Never
¨ Sometimes
¨ Very often

E1B.

Keeps desk clean and neat without being reminded
¨ Never
¨ Sometimes
¨ Very often

E1C.

Puts away work materials or other school property
¨ Never
¨ Sometimes
¨ Very often

E1D.

Uses time appropriately while waiting for your help with homework or some other task
¨ Never
¨ Sometimes
¨ Very often

E1F.

Finishes class assignments within time limits
¨ Never
¨ Sometimes
¨ Very often

E1G.

Produces correct schoolwork
¨ Never
¨ Sometimes
¨ Very often

E1H.

Follows your directions
¨ Never
¨ Sometimes
¨ Very often

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.6

E1I.

Ignores peer distractions when doing class work
¨ Never
¨ Sometimes
¨ Very often

E1J.

Attends to your instructions
¨ Never
¨ Sometimes
¨ Very often

E1K.

Easily makes transition from one classroom activity to another
¨ Never
¨ Sometimes
¨ Very often

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.7

Please rate the degree the child displays the following characteristics.

F1A.

Responds appropriately when hit or pushed by other children
¨ Never
¨ Sometimes
¨ Very often

F1B.

Receives criticism well
¨ Never
¨ Sometimes
¨ Very often

F1C.

Controls temper when arguing with other children
¨ Never
¨ Sometimes
¨ Very often

F1D.

Controls temper in conflict situations with adults
¨ Never
¨ Sometimes
¨ Very often

F1E.

Responds appropriately to teasing from friends or relatives of his or her own age
¨ Never
¨ Sometimes
¨ Very often

F1F.

Compromises in conflict situations by changing own ideas to reach agreement
¨ Never
¨ Sometimes
¨ Very often

F1I.

Cooperates with peers without prompting
¨ Never
¨ Sometimes
¨ Very often

F1J.

Gets along with people who are different
¨ Never
¨ Sometimes
¨ Very often
th

EHS 5 Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.8

D2A.

Disturbs ongoing activities
¨ Never
¨ Sometimes
¨ Very often

D2B.

Fidgets or moves too much
¨ Never
¨ Sometimes
¨ Very often

D2C.

Acts impulsively
¨ Never
¨ Sometimes
¨ Very often

D2D.

Doesn’t listen to what others say
¨ Never
¨ Sometimes
¨ Very often

D2E.

Is easily distracted
¨ Never
¨ Sometimes
¨ Very often

D2F.

Interrupts conversations of others
¨ Never
¨ Sometimes
¨ Very often

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.9

Please rate the degree the child displays the following characteristics.
D1A.

Argues a lot
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1B.

Cruelty, bullying, or meanness to others
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1C.

Defiant, talks back to staff
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1D.

Demands a lot of attention
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1E.

Destroys his/her own things
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1F.

Destroys property belonging to others
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1G.

Disobedient at school
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1H.

Gets in many fights
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.10

D1I.

Physically attacks people
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1J.

Explosive and unpredictable behavior
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1K.

Demands must be met immediately, easily frustrated
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1L.

Screams a lot
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1M.

Stubborn, sullen, or irritable
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1N.

Sudden changes in mood or feelings
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1O. Sulks a lot
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true
D1P.

Suspicious
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.11

D1Q.

Teases a lot
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1R.

Temper tantrums or hot temper
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

D1S. Threatens people
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true
D1T. Unusually loud
¨ Not true
¨ Somewhat or sometimes true
¨ Very true or often true

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.12

SECTION 3
CHILD’S USE OF SPECIAL SERVICES

I6.

Is the child receiving any special education or related services because of Attention
Deficit/Hyperactivity Disorder (ADD/ADHD)?

Do NOT include going to the nurse’s office to get medication dispensed.
¨ Yes
¨ No
I7.

Has the child received any of the following services this year at school during the school day?
A. Individual tutoring in reading/math.............................. ............ ¨ Yes ¨ No
B. Pull out or “push in” small group program in reading/math ....... ¨ Yes ¨ No
C. Pull out English as a Second Language (ESL)
program (instructional program designed to teach listening,
speaking, reading and writing English language skills) ............ ¨ Yes ¨ No
D. In-class English as a Second Language (ESL) program ......... ¨ Yes ¨ No
E. Learning a language other than English .................................. ¨ Yes ¨ No
F. Gifted and talented program ...................................... ............ ¨ Yes ¨ No
G. Counseling or psychological services...................................... ¨ Yes ¨ No
H. Audiology ............................................................................... ¨ Yes ¨ No
I. Occupational therapy................................................................ ¨ Yes ¨ No
J. Physical therapy ..................................................................... ¨ Yes ¨ No
K. Health services ....................................................................... ¨ Yes ¨ No
L. Special transportation.............................................................. ¨ Yes ¨ No
M. Speech or language therapy................................................... ¨ Yes ¨ No
N. Orientation services ................................................................ ¨ Yes ¨ No
O. Mobility services .................................................................... ¨ Yes ¨ No
P. Behavior Intervention Plan (BIP), in or out of the classroom .... ¨ Yes ¨ No

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.13

I8.

Has the child participated in any of the following Federally funded Tile I programs or services
offered by the school during this school year?
MARK ALL THAT APPLY.

A. Title I reading/English/language arts
¨Yes, individually
¨Yes, class-wide
¨ No; not offered
B. Title I ESL/Bilingual
¨Yes, individually
¨Yes, class-wide
¨ No; not offered
C. Title I handicapped/special education
¨Yes, individually
¨Yes, class-wide
¨ No; not offered

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.14

SECTION 4
YOUR RELATIONSHIP WITH THE CHILD’S PARENTS/GUARDIANS

C1.

During the school year, did the child’s parents/guardians attend a parent/teacher conference to
talk about the child’s progress?
¨ Yes
¨ No

C2.

If you had a problem with the child, how comfortable would you feel talking to his/her
parents/guardians about it?
¨ Not at all
¨ A little
¨ Somewhat
¨ A lot
¨ A great deal

C3.

How often do the child’s parents/guardians ask questions or make suggestions about the child?
¨ Not at all
¨ A little
¨ Somewhat
¨ A lot
¨ A great deal

C4.

How much do you feel the child’s parents/guardian have the same goals for their child that the
school does?
¨ Not at all
¨ A little
¨ Somewhat
¨ A lot
¨ A great deal

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.15

SECTION 5
SCHOOL CHARACTERISTICS

The following questions are about the child’s school.
A2.

Is this a public or private school?
¨ Public GO TO QUESTION A2.1
¨ Private GO TO QUESTION A2.2

A2.1
Is this public school a…
A. Regular public school (do not include a magnet school or school of choice).............. ¨Yes ¨ No
B. School with a magnet program
(e.g. science/math school, foreign language immersion school) ............................... ¨Yes ¨ No
C. School of choice (charter school, open enrollment, non-specialized curriculum) ....... ¨Yes ¨ No
D. Bureau of Indian Affairs (BIA) or tribal school ........................................................... ¨Yes ¨ No
E. Special Education school (primarily serves children with disabilities) ....................... ¨Yes ¨ No
A2.2
Is this private school a…
A. Catholic school ........................................................................................................ ¨Yes ¨ No
B. Private school not accredited by NAIS...................................................................... ¨Yes ¨ No
C. Private school accredited by NAIS ........................................................................... ¨Yes ¨ No
D. Special Education school (primarily serves children with disabilities) ........................ ¨Yes ¨ No

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.16

A3.

Circle the lowest grade taught in this school:
¨ Programs for special needs children
¨ Prekindergarten
¨ Regular kindergarten
¨ 1st
¨ 2nd
¨ 3rd
¨ 4th
¨ 5th
¨ 6th
¨ 7th
¨ 8th
¨ 9th
¨ 10th
¨ 11th
¨ 12th

A3.1.

Circle the highest grade taught in this school:
¨ Programs for special needs children
¨ Prekindergarten
¨ Regular kindergarten
¨ 1st
¨ 2nd
¨ 3rd
¨ 4th
th

¨5

¨ 6th
¨ 7th
¨ 8th
¨ 9th
th

¨ 10

¨ 11th
¨ 12th

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.17

SECTION 6
SCHOOL CLIMATE

Indicate how much you agree or disagree with the following statements about school climate:
J1A.

Parents are actively involved in this school’s programs
¨ Strongly disagree
¨ Disagree
¨ Neither agree nor disagree
¨ Agree
¨ Strongly agree

J1B.

Teacher absenteeism is a problem at this school
¨ Strongly disagree
¨ Disagree
¨ Neither agree nor disagree
¨ Agree
¨ Strongly agree

J1C.

Teacher turnover is a problem at this school
¨ Strongly disagree
¨ Disagree
¨ Neither agree nor disagree
¨ Agree
¨ Strongly agree

J1D.

Child absenteeism is a problem at this school
¨ Strongly disagree
¨ Disagree
¨ Neither agree nor disagree
¨ Agree
¨ Strongly agree

J1E.

Order and discipline are maintained satisfactorily in the building(s)
¨ Strongly disagree
¨ Disagree
¨ Neither agree nor disagree
¨ Agree
¨ Strongly agree

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.18

J1F.

Overcrowding is a problem at this school
¨ Strongly disagree
¨ Disagree
¨ Neither agree nor disagree
¨ Agree
¨ Strongly agree

J2.

Have any of the following types of problems happened during this school year at this school?
A. Children bringing weapons to school ...................................... ¨ Yes ¨ No
B. Things being taken directly from children or teachers by force
or threat of force at school or on the way to school...................... ¨ Yes ¨ No
C. Children or teachers being physically attacked ...................... ¨ Yes ¨ No
D. Children involved in physical fights ........................................ ¨ Yes ¨ No
E. Children bringing in or using alcohol at school ........................ ¨ Yes ¨ No
F. Children bringing in or using drugs at school .......................... ¨ Yes ¨ No
G. Vandalism of school property................................................. ¨ Yes ¨ No

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.19

SECTION 7
TEACHER CHARACTERISTICS
The following questions are about you as a teacher.
A4.

How do you classify your main assignment at this school, that is, the activity at which you spend
most of your time during this school year?
¨ Regular classroom teacher
¨ Special education teacher
¨ Itinerant teacher (i.e. your assignment requires you to provide instruction/related services at more than
one school)
¨ Long-term substitute (i.e., your assignment requires that you fill the role of a teacher

on

a long term basis, but you are still considered a substitute)
¨ Teacher aide
¨ Other (Specify: _____________________________)

A5.

Which category best describes the way your class(es) at this school (is/are) organized?
¨ Self-contained class – you teach multiple subjects to the same class of children all or most of the day
¨ Team teaching – you collaborate with one or more teachers in teaching multiple subjects to the same
class of children
¨ Departmentalized instruction –you teach subject matter courses (e.g. language arts, mathematics,
science) to several classes of different children all or most of the day
¨ “Pull-Out” Class – you provide instruction (e.g. special education, reading) to certain students who are
released from their regular classes

K1.

What is the highest level of education you have completed?

MARK ONLY ONE RESPONSE.

¨ High school diploma or GED
¨ Associate’s degree
¨ Bachelor’s degree
¨ At least 1 year of coursework beyond a bachelor’s, but not a graduate degree
¨ Master’s degree
¨ Education specialist or professional diploma based on at least one year of course work
past a Master’s degree level
¨ Doctorate
¨Other (please specify: ___________)

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.20

K2.

Counting this school year, how many years have you been a schoolteacher, including part-time
teaching?
________Years

K3.

What kind of teaching certification do you have?
¨ None
¨ Temporary or emergency certification
¨ Probational, provisional or transitional, certification
¨ Certification for completion of an alternative certification program
¨ Regular certification but less than the highest available
¨ The highest certification available (permanent or long term)

K4.

Are you certified in the following areas?
A. Elementary education ............................................... ¨ Yes ¨ No
B. Early childhood education ......................................... ¨ Yes ¨ No
C. Secondary education ................................................ ¨ Yes ¨ No
D. Reading specialist certification .................................. ¨ Yes ¨ No
E. Elementary mathematics........................................... ¨ Yes ¨ No
F. Middle/junior high school or secondary mathematics . ¨ Yes ¨ No
G. Elementary science .................................................. ¨ Yes ¨ No
H. Middle/junior high school or secondary science......... ¨ Yes ¨ No
I. ESL certification ......................................................... ¨ Yes ¨ No
J. Special education ...................................................... ¨ Yes ¨ No
K. Other (please specify: _______________) ................ ¨ Yes ¨ No

K5.

What is your gender?
¨ Male
¨ Female

K6.

What is your date of birth?
________/ ________/ ___________
Mo.
Day
Year

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.21

K7.

Are you of Hispanic or Latino origin?
¨ Yes
¨ No

K8.

Which describes your race?

PLEASE MARK ALL THAT APPLY.

¨ American Indian or Alaska Native
¨ Asian
¨ Black or African American
¨ Native Hawaiian or Other Pacific Islander
¨ White
¨ Other (please specify: _____________________________)

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.22

SECTION 8
CHILD’S SCHOOL RECORD SECTION
To answer the question in the following section, we would like you to consult the child’s school records
if necessary.

S1.

For this school year, date the child entered this school?
___/___/____

S2

Is the child currently still attending or enrolled in this school?
¨ Yes ¨ No

S3.

(IF NO LONGER IN SCHOOL) Date child left this school?
___/___/____

S4

(IF NO LONGER IN SCHOOL) Reason child left this school?
¨ Transfer
¨ Expulsion
¨ End of School Year
¨ Other Reason. Please Describe __________________

S5

For this school year, record in the table below the total number of absences for the child.
Please also indicate how many of these absences were excused and unexcused absences
Check if school does not maintain these records

¨

Number
Total Number of Absences
Number of Excused
Absences
Number of Unexcused
Absences

S6

For this school year, record in the table below the total number of times this child came late to
school and indicate how many of these times were excused and unexcused.
Check if school does not maintain these records

¨

Number
Total Number of Times Late
for School
Number of Excused Times
Late for School
Number of Unexcused
Times Late for School
EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.23

S7

In this school year, how many times was this child suspended from school?
______ Number of Times Suspended

S8

(IF SUSPENDED) How many total days was this child suspended in this school year?
______ Number of Days Suspended

S9.

In this school year did the child receive special education services through an Individualized
Education Program (IEP)?
¨ Yes
¨ No IF NO SKIP TO QUESTION S14.

S10.

What is the child’s primary disability as identified on the child’s IEP?
MARK ONLY ONE

¨ Learning disability
¨ Serious emotional disturbances
¨ Speech or language impairment
¨ Mental retardation
¨ Blind/Visual impairment
¨ Deaf/Hard of hearing
¨ Health impairment
¨ Orthopedic/Physical impairment
¨ Multiple impairments
¨ Deaf/blind
¨ Developmental delay
¨ Autism
¨ Traumatic brain injury
¨ No classification is given

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.24

S11.

Which of the following best describes the IEP goals for the child during this school year?
MARK ALL THAT APPLY
Academics
¨ Reading
¨ Mathematics
¨ Language arts
¨ Science
Speech and Language
¨ Auditory processing
¨ Listening comprehension
¨ Oral expression
¨ Voice/speech articulation
¨ Language pragmatics
Social
¨ Social skills
¨ Behavior goals
Life Skills
¨ Adaptive behavior or self-help skills
¨ Fine motor skills
¨ Gross motor skills
¨ Orientation and mobility
¨ Other (Specify: __________________________)

S12.

Approximately how many hours per week of direct special education and related services (that is,
services provided directly to the child from a teacher or another adult), is the child receiving in
this school year?
_______ Hours per week

S13.

Was the child’s primary placement in this school year in a general education classroom?
¨ Yes
¨ No

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.25

S14. Please provide the child’s test scores for the most recently administered standardized test.

Name of Test such as
the CAT or ITBS

Description of
Assessment or
Subject

Test Score

Type of
Score such
as Raw,
Scaled, or
T-Score

Grade
Level

Date
Administered

1
__/___/____
2
__/___/____
3
__/___/____
4
__/___/____

EHS 5th Grade Follow-Up Study, Appendix D, Teacher Questionnaire, 8/30/2006, p.26