Self-Administered Questionnaire

Appendix C.2. Self-Administered Questionnaire

U.S. Department of Labor
TAACCCT Round 4 Evaluation

Self-Administered Questionnaire

«Site_Name_1»

«ID»

Dear Participant:

The purpose of this form is to learn about some of the attitudes and skills that can affect people’s experiences in training and work. It should take you about 15 minutes to complete. At the beginning of each section is a short set of instructions. Please read these instructions carefully. Some of the questions ask you about your emotions or challenges you may be having. These questions may make you feel uncomfortable. This information is very important to the study, but you can refuse to answer any question. Program staff will not see your answers. The information will be used for research purposes only and will be kept private to the extent allowed by law. Your answers to these questions will not affect your chances of getting into this employment training program.

When you are finished, please seal this form in the envelope. ONLY seal the BLUE form in the envelope, and take the sealed envelope to the staff person. Thank you very much for helping us with this important study.

MARKING DIRECTIONS

 Use a blue or black ink pen or dark pencil.

 Do not use felt tip markers or gel pens.

 Put an “X” in the box that best describes your answer.

Correct:  □ □ □

 To change an answer, mark the new one and circle it.

Correct:  □  □

 Please PRINT where applicable. Enter only one letter or number per box: | J | O | B | S

Public Burden Statement, OMB #XXX, expires 00/00/0000.

Persons are not required to respond to this collection of information unless it displays a currently valid OMB Control Number. Respondent's obligation to reply is required to obtain benefits under P.L 111-5.  Public reporting burden for this collection of information is estimated to average 13 minutes per response, including the time for reading instructions, and completing and reviewing the requested information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Division of Adult Services, Room S-4209, Washington, D.C. 20210 (Paperwork Reduction Project Control No. 1205-0481NOA).

ATTITUDES ABOUT ONESELF

1. Below are some statements about how people approach various tasks in life. For each, please mark if you strongly agree, somewhat agree, somewhat disagree, or strongly disagree that the statement applies to you. Be honest—there are no right or wrong answers!

		Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree
a.	New ideas and projects sometimes distract me from previous ones.				
b.	Setbacks don’t discourage me.				
c.	I have been obsessed with a certain idea or project for a short time but later lost interest.				
d.	I am a hard worker.				
e.	I often set a goal but later choose to pursue a different one.				
f.	I often have difficulty maintaining my focus on projects that take more than a few months to complete.				
g.	I finish whatever I begin.				
h.	I am diligent.				

2. Next, please read the series of statements about your feelings about different aspects of life. For each one, please mark whether you strongly agree, somewhat agree, somewhat disagree, or strongly disagree with that statement:

		Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree
a.	I am confident I get the success I deserve in life.				
b.	Sometimes I feel depressed.				
c.	When I try, I generally succeed.				
d.	Sometimes when I fail I feel worthless.				
e.	I complete tasks successfully.				
f.	Sometimes, I do not feel in control of my work.				
g.	Overall, I am satisfied with myself.				
h.	I am filled with doubts about my competence.				
i.	I determine what will happen in my life.				
j.	I do not feel in control of my success in my career.				
k.	I am capable of coping with most of my problems.				
l.	There are times when things look pretty bleak and hopeless to me.				

3. The questions below ask you about your feelings and thoughts during the last month. The best approach is to answer each question fairly quickly, giving a reasonable estimate without trying to count up the exact number of times.

In the past month, how often have you felt:

	Never	Almost Never	Sometimes	Fairly Often	Very Often
That you were unable to control the important things in your life?					
Confident about your ability to handle your personal problems?					
That things were going your way?					
That difficulties were piling up so high that you could not overcome them?					

Math and Computer Skills

4. In everyday life, how often do you usually...

	Never	Less than once a month	Less than once a week, but at least once a month	At least once a week, but not every day	Every day
Use email?					
Use the internet in order to better understand issues related to, for example, your health or illnesses, financial matters, or environmental issues?					
Conduct transactions on the internet, for example buying or selling products or services, or banking?					
Use spreadsheet software, for example Excel?					
Use a word processor, for example Word?					
Use a programming language to program or write computer code?					
Participate in real-time discussions on the internet, for example online conferences or chat groups?					

5. Please rate each item in terms of how anxious you would feel during the event specified.

	Low Anxiety	Some Anxiety	Moderate Anxiety	Quite a bit of Anxiety	High Anxiety
Having to use the tables in the back of a math book.					
Thinking about an upcoming math test one day before.					
Watching a teacher work an algebraic equation on the blackboard.					
Taking an examination in a math course.					
Being given a homework assignment of many difficult problems which is due the next class meeting.					
Listening to a lecture in math class.					
Listening to another student explain a math formula.					
Being given a “pop” quiz in a math class.					
Starting a new chapter in a math book.					

Thank you for taking the time to complete these surveys!

Please seal this form and only this form in the envelope.

Then, locate the staff person and bring him/her your forms.