Student Language Background Survey

APPENDIX A

Student Language Background Survey: English Version

[This form will be available both in English and Spanish]

Your answers to these questions about your language background will be used as part of a research study about testing accommodations sponsored by the U.S. Department of Education and carried out by the Regional Educational Laboratory West (REL West) at WestEd. If you have questions about the study or this survey, please contact Carole Gallagher at (415)-615-3211 or at [email protected].

We estimate that it will take you about 5 minutes to complete this survey. Remember, there are no right or wrong answers, and you will not be graded on this task. Your participation is voluntary and you may refuse to answer any question.

For each question below, please fill in the blank with the information that best describes you.

1. My current grade is _______.

2. I am Male ______ Female _____ (check one).

3. I was born in _______________________ (name of country).

4. I lived there for ______ years.

5. I also lived in _______________(name of country) for ______ years.

6. I have lived in the United States for ______ years.

7. I have attended these grades in the U.S.: _____________________________.

8) We speak these languages in my home: _____________________________.

Thank you for your time!

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (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 response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  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, D.C. 20202-4651.  If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Rafael Valdivieso, U.S. Department of Education, 555 New Jersey Avenue, NW, Room 506E, Washington, D.C. 20208.

In accordance with The Education Sciences Reform Act of 2002, Title I, Part E, Section 183, 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.