Student Demographic Data

OMB Clearance Package for Study 2.1c

IPT & Student Data

IPT

(not included – standardized test)

(Site coordinators will administer the IPT. To the extent that the school does not already collect information on English Language Learner students reflected in the below Home Language Survey, site coordinators will also collect this information)

Student Demographic Data: HOME LANGUAGE SURVEY

Student ID: ________________________________ Grade:__________

Student Date of Birth: ____________ Gender (please circle): Male Female

Student Country of Birth: ________________________________

School: ________________________________ Current School Year: 200__

Does anyone in the student’s home speak a language other than English?	 YES  NO
What language(s) is/are spoken in the student’s home?
Does this student speak or understand a language other than English?	 YES  NO
What language did this student use when he/she first began to talk?
Can this student read the language listed above?	 YES, a lot  YES, a little  NO
Can this student write the language listed above?	 YES, a lot  YES, a little  NO
Does this student understand English?	 YES, a lot  YES, a little  NO
Does this student speak English?	 YES, a lot  YES, a little  NO
Does this student read English?	 YES, a lot  YES, a little  NO
Does this student write in English?	 YES, a lot  YES, a little  NO
Where did this student attend school last year (provide city, state, country)?
Was this student in a bilingual or ESL program during the last school year?	 YES  NO
Was this student ever in a bilingual or ESL program?	 YES  NO
If yes, what grade(s)? ______________________
If yes, where (city, school)? ______________________
Can an adult in the home speak English?	 YES  NO

Name of person completing this form: _______________________________________

The U.S. Department of Education wants to protect the privacy of individuals who participate in surveys.  Your answers will be combined with other surveys, and no one will know how you answered the questions.  This survey is authorized by law (1) Sections 171(b) and 173 of the Education Sciences Reform Act of 2002, Pub. L. 107-279 (2002); and (2) Section 9601 of the Elementary and Secondary Education Act (ESEA), as amended by the No Child Left Behind (NCLB) Act of 2001 (Pub. L. 107-110). Responses to this data collection will be used only for statistical purposes.  The reports prepared for this study will summarize findings across the sample and will not associate responses with a specific district or individual.  We will not provide information that identifies you or your district to anyone outside the study team, except as required by law. 

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 information collection is xxxx-xxxx. The time required to complete this information collection is estimated to average 5 minutes per respondent, including the time to review instructions, gather the data needed, and complete and review the information collected. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Washington, DC 20208.

A Study of the Differential Effects of ELL Training and Materials

Exhibit B: Data Collection Instruments