Student Background Interview

Adult ESL Literacy Impact Study

Student Background Interview

Survey Identification Number:
Student Code:	Site Code:
Date and Time:
Record comments, observations about interview, setting and student:

Paperwork Burden Statement

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 OMB control number. The valid OMB control number for this information collection is 1850-0811. The time required to complete this information collection is estimated to average 15 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: Melanie Ali, Institute of Education Sciences, U.S. Department of Education, Room 502B, 555 New Jersey Avenue, NW, Washington, DC 20208. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Dr. Larry Condelli, American Institutes for Research, 1000 Thomas Jefferson Street, N.W., Suite 400 Washington, DC 20007.

Confidentiality

Your responses are protected from disclosure by federal statute (P.L. 107-279, Title I, Part E, Sec.183). 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 purposes, unless otherwise compelled by law.

Introduction and Intake Data Verification

Hello, Mr./Ms. __________________, and thank you for taking the time to speak with me. The reason I am talking to you is to make sure that we have accurate information about your background.

Using the study database, identify if there are any blank intake fields and probe for a response.

• Name

• Address

• Phone (up to four numbers)

• Type (home, work, cell)

• E-mail address

• Alternative contact information (spouse, relatives, friends)

  • Relationship of contact to student

• Date of birth

• Sex

• Male

• Female

• Ethnicity

• Hispanic or Latino

• Not Hispanic or Latino

• Race

• White

• Black or African American

• Asian

• Native Hawaiian or Other Pacific Islander

• American Indian or Alaska Native

• Years in the U.S.

• Employment status

• Employed

• Unemployed

• Not in the labor force voluntarily (retired, student, homemaker)

• Country of origin

• Haiti

• Mexico

• China

• El Salvador

• Somalia

• Laos

• Ethiopia

• Guatemala

• Dominican Republic

• Honduras

• Other (Specify): ______________________

• First language(s)

• Spanish

• Haitian Creole

• French

• Somali

• Hmong

• Other (Specify): _____________________

• Other languages spoken at home (up to three)

• Total years of education

• Years of education in the U.S.

• Have you taken any other ESL classes in the U.S. before?

• If yes, when was the last time you took another ESL class:

  • Less than 6 months ago

  • At least 6 months but less than a year ago

  • At least 1 year but less than 2 years ago

  • At least 2 years but less than 5 years ago

  • 5 or more years ago

• Are you currently enrolled in another ESL class?

• Are you currently enrolled in school other than ESL?

• Are you enrolling in this class with:

  • Husband or wife

• Brother or sister

• Other relative

• Roommate/housemate

• Friend

• Other (Specify): ______________________

If any fields are blank  probe for any missing intake information, and record.

Thank you so much for verifying this information for us.

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