Teacher Background Form

APPENDIX G
TEACHER BACKGROUND FORM

OMB Number: l__l__l__l__l__l__l__l

Expiration Date: l__l__l__l

Study of Secondary Math Teachers from Alternative Routes to Certification
Teacher Background and Experience
When completed, please fax to Mathematica Policy Research, Inc. (MPR), toll-free, at ____________________.
If you have questions regarding this form, please call ____________________ at ______________________.
Teacher’s first and last name
District name
School name
Form completed by
1.

Which of the following statements best describes how this teacher entered the profession?
MARK (X) ONE STATEMENT
A

Entered through Teach For America

B

Entered through a Teaching Fellows or Teaching Residency program
Please mark (x) one program.

C

B1

… Baltimore City Teaching Residency

B8

… Oakland Teaching Fellows

B2

… Chicago Teaching Fellows

B9

… Philadelphia Teaching Fellows

B3

… DC Teaching Fellows

B10

… Prince George’s County Teaching Fellows

B4

… Indianapolis Teaching Fellows

B11

… Teach Charleston

B5

… Memphis Teaching Fellows

B12

… TeachNOLA

B6

… Miami Teaching Fellows

B13

… Texas Teaching Fellows

B7

… New York City Teaching Fellows

Entered after completing training for initial certification as part of a bachelor’s or master’s degree program
in education or related field (considered the traditional route to teacher certification)

D

Entered before completing all training and requirements for initial certification (considered an alternative
route to teacher certification).

Please mark (x) one program or list full program name below.

2.

D1

… Atlanta PLUS

D4

… Teaching Opportunity Program (TOP)

D2

… Career Transition Certification Program

D5

… TeachLA

D3

… Mississippi Teacher Corps

D6

… Massachusetts Initiative for New Teachers (MINT)

D99

… Other:

How many years has this teacher worked as a classroom teacher, including this school year?
l___l___l YEARS

3.

Please enter l_0_l_1_l
Please enter l_0_l_0_l

if worked less than one year
if this teacher has never worked in this capacity

If this teacher is selected to be in the study, the following information will be important in case we need to
contact him/her directly, not through the school. (Teachers will not be contacted if not in the study.)
Home or cell phone number
Home email address

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