1. What is your relationship to [9th grader]? Are you (his/her) biological (mother/father), adoptive (mother/father), step (mother/father) or someone else?
Biological Mother/Father
Adoptive Mother/Father
Stepmother/Stepfather
Foster Mother/Father
Female Partner of Parent/Guardian
Male Partner of Parent/Guardian
Grandmother/Father
Other Relative
Other Guardian
2. (If respondent is not a parent) Does one or both of [9th grader’s] biological or adoptive parents live in the same household as you and [9th grader]?
Yes, two parents
Yes, one parent
No, neither parent
3. (If respondent is a parent or neither parent lives in 9th grader’s household) Do you have a spouse or partner who lives in the same household as you and [9th grader]?
Yes, a spouse
Yes, a partner
No, not applicable
4. (If respondent is a parent who has a spouse or partner OR respondent is not a parent but one or both parents live in household) What is (your spouse’s/your partner’s/this parent’s/these parents’) relationship to [9th grader]?
Biological Mother/Father
Adoptive Mother/Father
Stepmother/Stepfather
Foster Mother/Father
Grandmother/Father
Other Female Relative
Other Male Relative
Other Female Guardian
Other Male Guardian
5. (If respondent is only parent in household) What is your current marital status? OR (If respondent is not a parent)
Married
Divorced
Separated
Never Married
Widowed
Don’t Know
6. What is [9th grader’s] parents’ current marital status? Are they?
Married
Divorced
Unmarried partners
Separated
Never Married
Widowed
Don’t Know
7. How much of the time does [9th grader] live with you (and your spouse/and your partner/and (his/her) parents)?
All of the time
More than half of the time
Half of the time
Less than half of the time
None of the time
8. With whom does [9th grader] live most of the time when (he/she) does not live with you?
With his/her other parent(s)
With another adult relative
With a friend
At boarding school
With a nonrelated adult guardian(s)
By himself/herself
Other_______________
9. How many brothers and sisters does [9th grader] have? Consider all siblings, including half- and step- and adoptive brothers and sisters, regardless of where they live.
None 1 2 3 4 5 6 or more
a. Full and/or adoptive brother(s) О О О О О О О
b. Half-brother(s) О О О О О О О
c. Step-brother(s) О О О О О О О
d. Full and/or adoptive sister(s) О О О О О О О
e. Half-sister(s) О О О О О О О
f. Step-sister(s) О О О О О О О
10. How many of these siblings are older than [9th grader]?
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11. Are you Hispanic or Latino/Latina?
Yes Go to question 12
No Skip to question 13
12. (If yes) Which one of the following are you?
Mexican, Mexican-American or Chicano
Other Hispanic
13. Please select one or more of the following choices to best describe your race.
White
Black/African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
14. (If Asian) Which one of the following are you?
Chinese
Filipino
Southeast Asian (Vietnamese, Thai, etc.)
South Asian (Asian Indian, Sri Lankan, etc.)
Other Asian
15. Is your (spouse/partner) Hispanic or (Latino/Latina)?
YesRouted to Q.12
No Go to Q.16
16. If yes: If your (spouse/partner) is Hispanic or Latino/Latina, please select one of the following choices best describes him/her:
Mexican, Mexican-American, Chicano
Other Hispanic or Other Latino/Latina
17. Please select one or more of the following choices to best describe your (spouse’s/partner’s) race. Is (he/she)…?
White
Black/African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
18. If you marked Asian, which of the following is your spouse/partner?
Chinese
Filipino
Southeast Asian (Vietnamese, Thai, etc.)
South Asian (Asian Indian, Sri Lankan, etc.}
Other Asian
19. In what country (were you/was [9th grader’s] mother) born?
U.S Skip to question 21
Not born in US Go to question 20
20. (If not born in U.S.) At what age did (you/she) come to the United States to stay?
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Years |
21. In what country (were you/ was [9th grader’s] father) born?
U.S Skip to question 23
Not born in US Go to question 22
22. (If not born in U.S.) How many years ago did (you/he) come to the United States to stay?
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Years |
23. In what country was [9th grader] born?
U.S Skip to question 25
Not born in US Go to question 24
24. (If not born in U.S.) How many years ago did [9th grader] come to the United States to stay?
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Years |
25. What grade was (he/she) placed in when (he/she) started school in the United States?
Pre-K
K
1-9
26. Is any language other than English regularly spoken in your home?
Yes Go to question 27
No Skip to question 28
27. (If yes) What languages other than English are spoken in your home?
Spanish
Another European language (for example, French, German, Russian, etc.)
A Chinese language
A Filipino language
A Southeast Asian language (for example, Vietnamese, Thai, etc.)
A South Asian Language (for example, Hindi, Tamil)
Another Asian Language (for example, Japanese, Korean)
A Middle Eastern Language (for example, Arabic, Farsi)
Other
28. Is English also spoken in your home?
Yes Go to questions 29 and 30
No Skip to question 31
29. (If yes) What language does [9th grader] usually speak to you in your home?
Spanish
Another European language (for example, French, German, Russian, etc.)
A Chinese language
A Filipino language
A Southeast Asian language (for example, Vietnamese, Cambodian, etc.)
A South Asian Language (for example, Hindi, Tamil)
Another Asian Language (for example, Japanese, Korean)
A Middle Eastern Language (for example, Arabic, Farsi)
other specify__________________
30. (If yes) What language do you usually speak to [9th grader] in your home?
Spanish
Another European language (for example, French, German, Russian, etc.)
A Chinese language
A Filipino language
A Southeast Asian language (for example, Vietnamese, Cambodian, etc.)
A South Asian Language (for example, Hindi, Tamil)
Another Asian Language (for example, Japanese, Korean)
A Middle Eastern Language (for example, Arabic, Farsi)
other specify__________________
31. Has [9th grader] ever been enrolled in an English as a Second Language (ESL) program?
Yes Go to question 32
No Skip to question 33
Don’t know
32. (If yes) Is [9th grader] currently enrolled in an English as a Second Language (ESL) program?
Yes
No
Don’t know
33. In what year (were you/was [9th grader’s] mother) born?
Year
1 |
9 |
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34. In what year (were you/was [9th grader’s] father) born?
Year
1 |
9 |
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35. What is the highest level of education you and your spouse/partner have reached? REMINDER: Use “spouse/partner” definition from Question 2 or Question 3.
(mark one response in each column)
You Your Spouse/
Partner
a. Did not finish high school
b. Graduated from high school or equivalent (GED)
c. Started but have not completed a degree from a 2-year school or college (such as a vocational or technical school or a junior or community college)
d. Graduated from a 2-year school (such as a vocational or technical school, a junior college, or a community college)
e. Started but have not completed a 4-year college degree
f. Graduated from a 4-year college
g. Started but have not completed a Master’s degree
h. Completed a Master’s degree or equivalent
i. Started but have not completed a Ph.D., M.D., or other advanced professional degree program
j. Completed a Ph.D., M.D., or other advanced professional degree
36. (If at least associate’s degree) What was (your) major area of study for (your) [highest degree]?
_____________________________________________________
37. What is the highest level of education (your spouse/your partner/[9th-grader’s] father) has completed?
_____________________________________________________
38. (If at least associate’s degree) What was (his/her) major area of study for (his/her) [highest degree]?
______________________________________________________
39. During the past week, did (you/[9th grader’s] mother) hold a job for pay or income?
Yes Go to question 40
No Skip to question 41
Not applicable Skip to question 41
40. (If yes) About how many total hours per week do (you/[9th grader’s] mother) usually work for pay or income, counting all jobs?
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Total hours per week |
41. What is (your/her) job title? If (you/she) had more than one job, describe the one at which (you/she) worked the most hours.
_______________________________________________
42. What (do you/does she) actually do in that job? That is, what are (your/her) main activities or duties?
________________________________________________
43. During the past week, did (your spouse/your partner/[9th grader’s] father) hold a job for pay or income?
Yes Go to question 44
No Skip to question 45
44. (If yes) About how many total hours per week does (your spouse/your partner/[9th grader’s father) usually work for pay or income, counting all jobs?
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Total hours per week |
45. What is (his/her) job title? If (he/she) had more than one job, describe the one at which (he/she) worked the most hours.
___________________________________________________________
46. What (do you/does he) actually do in that job? That is, what are (your/his) main activities or duties?
____________________________________________________________
47. What was your total household income from all sources (including income from work, investment income, alimony, etc.) prior to taxes and deductions in calendar year 2008?
(Verbatim) (if verbatim refused, ask 48)
48. (If 47 refused) Please indicate the range that best estimates your total household income from all sources (including income from work, investments, alimony, etc.), prior to taxes and deductions, for calendar year 2007.
$14,999 or less
$15,000 - $34,999
$35,000 - $54,999
$55,000 - $74,999
$75,000 - $94,999
$95,000 - $114,999
$115,000 - $134,999
$135,000 - $154,999
$155,000 - $174,999
$175,000 - $194,999
$195,000 - $214,999
$215,000 - $234,999
$235,000 and above
49. Do you?
Own or pay mortgage on your home
Rent your home
Or have some other arrangement
50. Since starting kindergarten, has [9th grader] repeated any grades?
Yes Go to question 51
No Skip to question 52
51. (If yes) What grades did (he/she) repeat? (Mark all that apply)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
52. Since starting kindergarten, has [9th grader] skipped any grades?
Yes Go to Question 53
No Skip to Question 54
53. (If yes) What grade(s) did (he/she) skip? (Mark all that apply)
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
54. How many times has [9th grader] changed schools since he/she first entered school? Do not count changes that occurred as a result of promotion to the next grade or level (for example, a move from an elementary school to from a middle school or from a middle school to a high school in the same district). Please enter zero if your 9th grader has not changed schools except for promotion.
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Total times changed schools |
55. Since the first grade, has [9th grader] ever stopped going to school for a period of a month or more other than for illness, injury or vacation?
Yes
No
56. Since the first grade, has [9th grader] ever been suspended (not counting detentions) or expelled from school?
Yes
No
57. During the last school year, how many times did [9th grader’s] school contact you (or your spouse/partner) about...?
Never Rarely Sometimes Often
a. [9th grader’s] behavior in school О О О О
b. [9th grader’s] attendance record at school O О О О
c. [9th grader’s] academic performance O О О О
58. Did [9th grader] take algebra in either the 7th or 8th grade?
Yes
No
Don’t know
59. How often did you talk with other parents about teachers, courses, or school events...?
Never Rarely Sometimes Often
a. at [9th grader’s] 8th grade school? О О О О
b. at [9th grader’s] current school? O О О О
60. Did you (or your spouse/partner) attend an open house or orientation at [9th grader’s] high school before this school year began?
Yes
No
61. Did you request that [9th grader] get or not get a particular 9th grade teacher or course at (his/her) high school?
Yes
No
62. In the past year, how often did you (and your spouse/partner) discuss the following subjects with [9th grader]?
Never Rarely Sometimes Often
a. Selecting courses or programs at school О О О О
b. School activities or events О О О О
c. Things [9th grader] has studied in class О О О О
d. [9th grader’s] grades О О О О
e. Your [9th grader’s] plans after leaving
high school О О О О
f. Applying to colleges or
other schools after high school О О О О
g. Jobs [9th grader] might like to have when
(he/she) grows up О О О О
63. How much influence do you think you have on the choices [9th grader] makes about school?
None
A little
Some
A lot
X1. During the last school year, how often did you and your spouse/partner help [9th grader] with his/her homework?
Never
Less than once a week
Once or twice a week
3 or 4 times a week
5 or more times a week
X2. How confident do you feel about your ability to help [9th grader] in each of the following subjects?
Very Somewhat Not
at all
confident confident confident
a. The math your 9th grader has this year О О О
b. The science your 9th grader has this year О О О
c. The English composition, literature, or reading your 9th grader has this year О О О
64. Are there family rules that are enforced for [9th grader] about the following activities?
Yes No
a. Earning acceptable grades in school О О
b. Doing homework О О
X3. Do you or [9th grader's] (mother/stepmother/foster mother/father/stepfather/foster father) (or another adult in your household) check to see that (his/her) homework is done?
Yes
No
65. In a typical week, what is the latest [9th grader] can stay out on school nights (Sunday - Thursday)?
Not allowed out
No later than 8:00 PM
No later than 9:00 PM
No later than 10:00 PM
No later than 11:00 PM
No later than midnight
As late as (he/she) wants
66. In your opinion, does [9th grader] have a specific learning disability?
Yes
No
Don’t know
67. Does your [9th grader] currently have an Individualized Education Plan (IEP)?
Yes Go to question 68
No Skip to question 69
Don’t know Skip to question 69
68. What is the main disability category for your 9th grader’s IEP? (Mark one)
Autism
Deafness
Deaf-blindness
Emotional disturbance
Hearing impairment
Learning disability
Mental retardation
Multiple disabilities
Orthopedic impairment
Other health impairment
Speech or language impairment
Traumatic brain injury
Visual impairment (including blindness)
69. Has [9th grader] ever been diagnosed by a doctor as having a specific learning disability?
Yes
No
Don’t know
70. Is [9th grader] currently enrolled in a gifted and talented education (GATE) program?
Yes
No
Don’t know
71. From the start of 8th grade until now, did [9th grader] have any academic instruction outside of school such as from a Saturday Academy, learning center, personal tutor or summer school program?
Yes Go to Question 72
No Skip to Question 74
72. (If yes) In what subjects was this instruction?
Reading
Math
Science
Writing
Other (specify)________________
73. Was the purpose of any of this instruction to help your 9th grader catch up in school?
Yes
No
74. During the last 12 months, has [9th grader] participated in any of the following activities outside of school?
Yes No
a. Music, dance, art, or theater О О
b. Organized sports supervised by an adult О О
c. Religious youth group or religious instruction О О
d. Scouting or another group or club activity О О
e. A math or science camp О О
f. Another camp О O
g. Any other regular activities or lessons О О
75. In the past year, that is, since {month, day}, has anyone in your family done the following activities with your 9th grader?
Yes No
a. Visited a zoo, planetarium, natural history museum,
transportation museum, or a similar museum? О О
b. Worked or played on a computer together? О О
c. Built or fixed something such as a vehicle or appliance? О О
d. Attended a school science fair? О О
e. Helped [9th grader] with a school science fair project? О О
f. Discussed a program or article about math,
science, or technology? О O
g. Another science, technology, engineering
or math-related activity? (specify)___________________ О О
76. How would you compare boys and girls in...?
Girls are Girls Girls and boys Boys Boys
much are somewhat are the are somewhat are much
better better same better better
a. Reading О О О О О
b. Math О О О О О
c. Writing О О О О О
d. Science О О О О О
77. How important do you think the following subjects are for your 9th grader to meet (her/his) educational goals?
Extremely Somewhat
Important Important Important Unimportant
a. Reading О О О О
b. Math О О О О
c. Writing О О О О
d. Science О О О О
78. How far in school do you want [9th grader] to go? (Please mark only the highest level that applies)
Did not finish high school
Graduated from high school or equivalent (GED)
Started but have not completed a degree from a 2-year school or college (such as a vocational or technical school or a junior or community college)
Graduated from a 2-year school (such as a vocational or technical school, a junior college, or a community college)
Started but have not completed a 4-year college degree
Graduated from a 4-year college
Started but have not completed a Master’s degree
Completed a Master’s degree or equivalent
Started but have not completed a Ph.D., M.D., or other advanced professional degree program
Completed a Ph.D., M.D., or other advanced professional degree
79. As things stand now, how far in school do you think [9th grader] will actually get? (Please mark only the highest level that applies)
Not finish high school.
Graduate from high school or equivalent (GED)
Graduate from high school and attend a 2-year school (such as a
vocational or technical school, a junior college, or a community college)
but not complete a degree
Graduate from a 2-year school (such as a vocational or technical school,
a junior college, or a community college)
Graduate from high school and go to
college but not complete a 4-year degree
Graduate from college
Obtain a Master’s degree or equivalent
Obtain a PhD, MD, or other advanced degree
Don’t know
80. (If thinks 9th grader will continue education after high school) Do you think [9th grader] will start (his/her) college education at a:
Vocational or trade school
2-year school
4-year school
I have not thought about this yet
81. Do you or does anyone in your family plan to help [9th grader] pay for (his/her) education after high school?
Yes
No
Or you have not thought about this yet?
82. Did anyone help you to complete this questionnaire?
Yes
No
83. Who assisted with questionnaire completion?
My ninth grader named on the front cover
Another family member
One of my friends
Another person in the community
84. Parent’s Name
________________________________________
Last Name First Name MI
85. Address
__________________________________________
(Include
number, street, apartment number, P.O. Box,
etc.)
________________________________________
City, State, Zip code
86. Home telephone
(______)___________
Area Code
87. Business phone
(______)__________Ext. ___________
Area Code
88. Cell phone
(______)____________
Area Code
89. E-mail address
______________________________________
90. SSN
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- |
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- |
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91. Student’s SSN
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- |
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- |
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92. Nonresident parent’s name
________________________________________
Last Name First Name MI
93. Address
__________________________________________
(Include
number, street, apartment number, P.O. Box,
etc)
________________________________________
City, State, Zip code
94. Home telephone
(______)___________
Area Code
95. Business phone
(______)__________ Ext. ___________
Area Code
96. Relative’s name
________________________________________
Last Name First Name MI
97. Address
__________________________________________
(Include
number, street, apartment number, P.O. Box,
etc.)
_______________________________________________
City, State,
Zip code
98. Home Telephone
(______)___________
Area Code
99. Relative’s relationship to parent
_________________________________________
100. Close friend’s name
______________________________________________
Last Name First Name MI
101. Address
_________________________________________
(Include
number, street, apartment number, P.O. Box,
etc.)
_____________________________________________
City, State, Zip
code
102. Home Telephone
(______)___________________________
Area Code
Appendix D -
File Type | application/msword |
File Title | Data Element |
Author | cbthompson |
Last Modified By | DoED User |
File Modified | 2008-07-09 |
File Created | 2008-07-09 |