Teachers Demographics

Appendix J

A

OMB Number: xxxx-xxxx

Expiration Date: xx/xx/xx

ppendix J

Teacher Demographics Form

Teacher Name School Name

Teacher Number _________ School Number________

Birth Date (Month, Day, Year): ___/_____/____

1. What is your gender? _____Female _____Male

2. What is your race? _____African American _____American Indian

(Select one or more) _____White _____Pacific Islander/Hawaiian

_____Asian _____Multiracial

_____Unknown

2. What is your ethnicity? _____Hispanic

_____Non-Hispanic

_____Unknown

2. EDUCATIONAL BACKGROUND AND PROFESSIONAL EXPERIENCE

Please check and complete for all that apply.

	Education	Major	Year Completed
	High School
	GED
	Non-degree program (e.g. Montessori, CDA)
	Some college/university
	Bachelor’s degree
	Some graduate level classes
	Master’s degree
	Education Specialist
	Doctorate

2. Please check all areas in which you have a current teaching certificate.

	Early Childhood			Gifted/Talented
	Middle Childhood			Administration
	Secondary			Reading
	ESOL			Other
	Special Education

2. Do you have any other special training? _____Yes _____No

Please describe. __________________________________________________________

2. How many years have you been teaching? ___________

3. How many years have you been teaching kindergarten? ___________

1

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.