> OMB No. 1850-0598: Approval Expires XX/XX/XXXX

U.S DEPARTMENT OF EDUCATION Conducted by: U.S. Department of Commerce

National Center for Education Statistics U.S. Census Bureau

PRIVATE SCHOOL TEACHER QUESTIONNAIRE

SCHOOLS AND STAFFING SURVEY

2007-08 SCHOOL YEAR

THIS SURVEY HAS BEEN ENDORSED BY:

American Montessori Society National Association of Independent Schools

Association of Boarding Schools National Association of Private Special
Education Centers

Association of Christian Schools International National Catholic
Educational Association

Association of Christian Teachers and Schools National Christian School
Association

Association of Waldorf Schools of North America National Coalition of
Girls' Schools

Christian Schools International National Council for Private School
Accreditation

Council for American Private Education National Independent Private
Schools Association

Council of Islamic Schools in North America North American Division of
Seventh-Day Adventists

Evangelical Lutheran Church in America Oral Roberts University
Educational Fellowship

Islamic School League of America Solomon Schechter Day School
Association

Jesuit Secondary Education Association Toussaint Institute Fund

Lutheran Church-Missouri Synod United States Conference of Catholic
Bishops

National Association of Episcopal Schools Wisconsin Evangelical Lutheran
Synod

NOTICE: This survey is authorized by Title I, Part E, Sections 151(b)
and 153(a) of Public Law 107-279, the Education Sciences Reform Act of
2002.

DEAR TEACHER:

The Schools and Staffing Survey is the largest sample survey of
America's elementary and secondary schools. Your participation is
important. Below are answers to some general questions.

WHAT IS THE PURPOSE OF THIS SURVEY?

The purpose of this survey is to obtain information about teachers such
as professional background, teaching field, and workload.

WHO IS CONDUCTING THIS SURVEY?

The U.S. Census Bureau is conducting this survey for the National Center
for Education Statistics

(NCES) of the U.S. Department of Education.

WHY SHOULD YOU PARTICIPATE IN THIS SURVEY?

Policymakers and educational leaders rely on data from this survey to
inform their decisions concerning K-12 schools. Because it is a sample
survey, your responses represent the responses of many. Higher response
rates give us confidence that the findings are accurate.

WILL YOUR RESPONSES BE KEPT CONFIDENTIAL?

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 purpose, unless otherwise compelled by
law.

HOW WILL YOUR INFORMATION BE REPORTED?

The information you provide will be combined with the information
provided by others in statistical reports. No individual data that links
your name, address, or telephone number with your responses will be
included in the statistical reports.

WHERE SHOULD YOU MAIL YOUR COMPLETED QUESTIONNAIRE?

Please return your completed questionnaire in the enclosed preaddressed,
postage-paid envelope, or mail it to:

U.S. CENSUS BUREAU

ATTN: SPB 64C

1201 E. 10th STREET

JEFFERSONVILLE, IN 47132-0001

WE HOPE YOU WILL PARTICIPATE IN THIS VOLUNTARY SURVEY.

SINCERELY,

**MARK SCHNEIDER**

**COMMISSIONER for EDUCATION STATISTICS**

**NATIONAL CENTER FOR EDUCATION STATISTICS**

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 1850-0598. The time required
to complete this information collection is estimated to average XX
minutes per response, including the time spent 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 about the contents of this
questionnaire, email: <sassdata@ed.gov>, or write directly to: Schools
and Staffing Survey, National Center for Education Statistics, 1990 K
Street, N.W., #9018, Washington DC 20006.

**INSTRUCTIONS**

The data you enter on this form will be captured through the use of
imaging technology. Please print all information clearly in ordinary
characters, using a black ball point pen.

**a.** If you are the teacher named on the cover page label, please
complete the questionnaire.

**b.** Please do not write any comments near the answer boxes.

**c.** If you are unsure about how to answer a question, please give the
best answer you can

rather than leave it blank.

**d.** If you have any questions, call the Census Bureau at
1-800-221-1204. Someone will

be available to take your call Monday through Friday, between 8:30 a.m.
and 5:00 p.m.

(Eastern Time). The Census Bureau is also available to answer your
questions via

e-mail at: <dsd.sass@census.gov>.

**e.** At the end of the survey, you will be asked how long it took to
complete this questionnaire.

Please record the time you begin.

**\_\_:\_\_** Time started

**Please correct any errors in name, address, and ZIP code.**

Teacher name

0010

School name

0011

Address

0012

City State Zip code

0013 0014 0015

I. GENERAL INFORMATION

1\. How do you classify your position at THIS school, that is, the
activity at which you spend most of your time during this school year?

> *\*Mark (X) only one box.*

0026 1\_\_ Regular full-time teacher

> 2\_\_ Regular part-time teacher
>
> 3\_\_Itinerant teacher (i.e., your assignment requires you to provide
> instruction at more than one school)
>
> 4\_\_Long-term substitute (i.e., your assignment requires that you
> fill the role of a regular teacher on a long-term basis, but you are
> still considered a substitute)
>
> 5\_\_ Short-term substitute
>
> 6\_\_ Student teacher
>
> 7\_\_ Teacher aide
>
> 8\_\_ Administrator (e.g., principal, assistant principal, director,
> school head)
>
> 9\_\_ Library media specialist or librarian
>
> 10\_\_Other professional staff (e.g., counselor, curriculum
> coordinator, social worker)
>
> 11\_\_ Support staff (e.g., secretary)

2\. Which box did you mark in item 1 above?

0027 1\_\_ Box 1 à GO TO item 5 \[on page \# related to item 5/below\].

2\_\_ Box 2,3, or 4 à GO TO item 4 \[on page \# related to item
4/below\].

> 3\_\_Box 5,6 or 7 à Please STOP now and return this questionnaire to
> your field representative. Thank you for your time.
>
> 4\_\_Box 8,9,10 or 11

3\. Do you TEACH any regularly scheduled class(es) at this school?

*\*If you work as a library media specialist or librarian at this
school, do not include classes in which you teach students how to use
the library (e.g., library skills or library research).*

0028 1_Yes à GO TO item 4 \[page \# related to item 4/below\].

2_No à Please STOP now and return this questionnaire to your field
representative. Thank you for your time.

4\. How much time do you work as a TEACHER at THIS school?

*\*Mark (X) only one box.*

0029 1\_ Full time

2\_ ¾ time or more, but less than full-time

3\_ ½ time or more, but less than ¾ time

4\_ ¼ time or more, but less than ½ time

5\_ Less than ¼ time

**5. How many days are covered by your contract?**

\*Include professional development, student contact days, and any other
days covered by your contract.

NEW /\_\_/\_\_/\_\_/ Days

**6.What was your MAIN activity LAST school year (2006-07)?**

*\*Mark (X) only one box.*

0030 1\_ Teaching in this school

3_Teaching in another private elementary or secondary school IN THIS
STATE

4\_ Teaching in a private elementary or secondary school IN ANOTHER
STATE

5\_ Teaching in a PUBLIC elementary or secondary school

6\_ Student at a college or university

7\_ Teaching in a preschool

8_Teaching at a college or university

9_Working in a position in the field of education, but not as a teacher

10\_ Working in an occupation outside the field of education

11\_ Caring for family members

12\_ Military service

13\_ Unemployed and seeking work

14 \_ Retired from another job

15\_ Other -- please specifyà5030
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**7a. Did you mark box 9 (Working in an occupation outside the field of
education) in item 6?**

0031 \_Yes

\_No à GO TO item 8 on \[page \# related to item 8/below\].

**b. What kind of work did you do, that is, what was your occupation?**

*\*Please record your job title; for example, plumber, typist, or
farmer.*

5031
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**c. What were your usual activities or duties at this job?**

*\*For example, typing, keeping account books, filing, selling cars,
operating printing press, laying brick.*

9001\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**d. In addition to these usual activities, were you also teaching in
one or more of grades K-12 last school year?**

0032 \_Yes

> \_No à GO TO item 8\[on page \# related to item 8/below\].

**e. How would you classify that teaching position?**

*\*Mark (X) only one box.*

0033 \_Regular full-time teacher

> \_Regular part-time teacher
>
> \_Substitute teacher
>
> \_Itinerant teacher
>
> \_Other -- please specify à
>
> 5033\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

8\. In what year did you begin teaching in THIS school?

\**If you have had a break in service of **one year or more**, please
report the year that you returned to this school.*

\**Do not include time spent as a student teacher.*

> 0034 /\_\_/\_\_/\_\_/\_\_/ Year

**9. In what year did you begin teaching, either full-time or part-time,
at the elementary or secondary level?**

\**Do not include time spent as a student teacher.*

> 0035 /\_\_/\_\_/ \_\_/\_\_/ Year

**10a.** **How many years have you worked as a FULL-TIME elementary or
secondary teacher in**

**PRIVATE schools**?

*\*Include the current school year if you are a full-time teacher this
year.*

*\*Record whole years, not fractions or months.*

*\*If none, please mark (X) the box.*

0036 \_\_None or /\_\_/\_\_/ Year(s)

**b. How many years have you worked as a PART-TIME elementary or
secondary teacher in PRIVATE schools?**

*\*Include the current school year if you are a part-time teacher this
year.*

*\*Record whole years, not fractions or months.*

*\*If none, please mark (X) the box.*

0037 \_\_None or /\_\_/\_\_/ Year(s)

**11a.** **Have you ever worked as an elementary or secondary teacher in
a PUBLIC school?**

0038 \_Yes

\_Noà GO TO item 12 on page \_

**b.** **How many years did you teach FULL-TIME in a public school?**

*\*Count part of a school year as 1 year.*

*\*Record whole years, not fractions or months.*

*\*If none, please mark (X) the box.*

0039 \_\_None or /\_\_/\_\_/ Year(s)

**c.** **How many years did you teach PART-TIME in a public school?**

*\*Count part of a school year as 1 year.*

*\*Record whole years, not fractions or months.*

*\*If none, please mark (X) the box.*

0040 \_\_None or /\_\_/\_\_/ Year(s)

Table 1. Teaching Assignment and Subject Matter Codes

For question 15 and 22

**General Education**

## Elementary Education

101 Early childhood or pre-K, general

102 Elementary grades, general

# [Subject Matter Specific -- FORM TEAMS, please center]{.mark}

## Arts and Music

141 Art or arts or crafts

143 Dance

144 Drama or theater

145 Music

## 

## English and Language Arts

151 Communications

152 Composition

153 English

154 Journalism

155 Language arts

158 Reading

159 Speech

## English as a Second Language

160 ESL or bilingual education: general

161 ESL or bilingual education: Spanish

162 ESL or bilingual education: other languages

## Foreign Languages

171 French

172 German

173 Latin

174 Spanish

175 Other foreign language

## Health Education

181 Health education

182 Physical education

## Mathematics and Computer Science

## 191 Algebra I

192 Algebra II

193 Algebra III

194 Basic and general mathematics

195 Business and applied math

196 Calculus and pre-calculus

197 Computer science

198 Geometry

199 Pre-algebra

200 Statistics and probability

201 Trigonometry

## 

## Natural Sciences 

210 Science, general

211 Biology or life sciences

212 Chemistry

213 Earth sciences

215 Integrated science

216 Physical science

217 Physics

**Special Education**

110 Special education, any

## 

## Social Sciences

220 Social studies, general

221 Anthropology

225 Economics

226 Geography

227 Government or civics

228 History

231 Native American studies

233 Psychology

234 Sociology

## Career, Technical, or Vocational Education

241 Agriculture and natural resources

242 Business management

243 Business support

244 Marketing and distribution

245 Health occupations

246 Construction trades, engineering, or science technologies (including
CADD and drafting)

247 Mechanics and repair

249 Manufacturing or precision production (electronics, metalwork,
textiles, etc.)

250 Communications and related technologies (including design, graphics
or printing; not including computer science)

253 Personal and public services (including culinary arts, cosmetology,
child care, social work, protective services, custodial services, and
interior design)

254 Family and consumer sciences education

255 Industrial arts or technology education

256 Other career, technical, or vocational education

## Miscellaneous

262 Driver education

264 Library or information science

265 Military science or ROTC

266 Philosophy

267 Religious studies, theology, or divinity

## Other

268 Other

**II. CLASS ORGANIZATION**

12\. In which grades are ALL of the STUDENTS you currently teach at THIS
school?

*\*Mark (x) all that apply.*

0051 \_\_Prekindergarten 0055 \_\_3^rd^ 0059 \_\_7^th^ 0063 \_\_11^th^

0052 \_\_Kindergarten 0056 \_\_4^th^ 0060 \_\_8^th^ 0064 \_\_12^th^

0053 \_\_1^st^ 0057 \_\_5^th^ 0061 \_\_9^th^ 0065 \_\_Ungraded

> 0054 \_\_2^nd^ 0058 \_\_6^th^ 0062 \_\_10^th^

**13. Of all the students you teach at this school, how many have a
formally identified disability?**

(A student with an identified disability may or may not have an IEP
(Individualized Education Program) or Services Plan.)

*\*If none, please mark (X) the box.*

\_None à GO TO item 14 \[on page \# related to item 14/below\].

0279 /\_\_/\_\_/\_\_/ Students

14\. Of all the students you teach at this school, how many are of
limited-English proficiency?

(Students of limited-English proficiency \[LEP\] are those whose native
or dominant language is other than English, and who have sufficient
difficulty speaking, reading, writing, or understanding the English
language as to deny them the opportunity to learn successfully in an
English-speaking-only classroom.)

*\*If none, please mark (X) the box.*

0284 \_\_None à GO TO item 15 \[on page \# related to item 14/below\].

/\_\_/\_\_/\_\_/ Students

15\. This school year, what is your MAIN teaching assignment field at
THIS school?

(Your main assignment is the field in which you teach the most classes.)

*\*Record one of the assignment field codes listed in Table 1 \[on page
\# related to Table 1\].*

0069 \_\_\_\_\_ Code 5069
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Main assignment

16\. Which statement best describes the way YOUR classes at THIS school
are organized?

\**Mark (x) only one box.*

0066 (1)\_\_\_ You instruct several classes of different students most
or all of the day in one or more subjects (sometimes called
Departmentalized Instruction).

> \(2\) \_\_ You are an elementary school teacher who teaches only one
> subject to different classes of students (sometimes called an
> Elementary Subject Specialist).
>
> (3)\_\_\_ You instruct the same group of students all or most of the
> day in multiple subjects (sometimes called a Self-Contained Class).
>
> (4)\_\_\_ You are one of two or more teachers, in the same class, at
> the same time, and are jointly responsible for teaching the same group
> of students all or most of the day (sometimes called Team Teaching).
>
> \(5\) \_\_\_ You instruct a small number of selected students released
> from or in their regular classes in specific skills or to address
> specific needs (sometimes called a "Pull-Out" Class or "Push-In"
> Instruction).

**17. Check the box you marked in item 16 \[on page \# related to item
16/above\] and follow the arrow for the next item.**

0067 \_\_ Box 1 (Departmentalized Instruction) à GO TO item 21 \[on page
\# related to item 21/below\].

> \_\_ Box 2 (Elementary Subject Specialist) à GO TO item 21 \[on page
> \# related to item 21/below\].
>
> \_\_ Box 3 (Self-Contained Class) à GO TO item 18 \[on page \# related
> to item 18/below\].
>
> \_\_ Box 4 (Team Teaching) à GO TO item 18 \[on page \# related to
> item 18/below\].
>
> \_\_ Box 5 (Pull-Out Class or Push-In Instruction)à GO TO item 19 \[on
> page \# related to item 19/below\].

**18. During your most recent FULL WEEK of teaching at THIS school, what
is the total number of students enrolled in the class you taught?**

0068 /\_\_/\_\_/ Students

**19. During your most recent FULL WEEK of teaching at THIS school, what
is the average number of students you taught at any one time?**

/\_\_/\_\_/ Students

20\. During your most recent FULL WEEK of teaching, approximately how
many hours did you spend teaching each of the following subjects at THIS
school?

\**If you taught two or more subjects at the same time, apportion the
time to each subject the best you can.*

\**Report hours to the nearest whole hour; do not record fractions of an
hour or minutes.*

\**If you did not teach a particular subject during the week, mark (X)
the "None" box.*

a.  **English/Reading/Language Arts (including reading and writing)**

> 0070 \_\_None **or** /\_\_/\_\_/ Hours per week

**(1) Of these hours, how many were designated for reading
instruction?**

> 0071 \_\_None **or** /\_\_/\_\_/ Hours per week

b.  **Arithmetic, Mathematics**

> 0072 \_\_None **or** /\_\_/\_\_/ Hours per week

b.  **Social studies or History**

> 0073 \_\_None **or** /\_\_/\_\_/ Hours per week

c.  **Science**

> 0074 \_\_None **or** /\_\_/\_\_/ Hours per week

**GO TO item 23a \[on page \# related to item 23a/below\].**

Note: Items 21-22 are for teachers who marked box 1 or 2 for item 17. If
you marked box

3, 4, or 5 for item 17 (and completed items 18-19), go to item 23a \[on
page \# related to item 23a/below\].

21\. How many separate class periods or sections do you currently teach
at THIS school?

*\*Do not include homeroom periods or study halls.*

*(Example: If you teach 2 classes \[or sections\] of chemistry I, a
class \[or section\] of physics I, and a class \[or section\] of physics
II, you would report 04 classes \[or sections\].)*

0076 /\_\_/\_\_/ Number of classes (or sections)

**22. For EACH class period or section that you reported in item 21,
record the subject name, subject matter code, grade level code, and
number of students.**

\*MIXED GRADES: List the grade with the most number of students.

\*The number of lines filled out should equal the number of class
periods or sections reported in item 21.

\*Record the code for subject matter in Table 1.

**A. Subject Name B. Subject C. Grade Level D. Number of students**

**Matter Code Code**

Example

A. [English\_\_\_\_\_\_\_\_\_\_]{.underline} B. [153]{.underline} C.
[11]{.underline} D. [33]{.underline}

5077 (1) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0077 \_\_ 0078 \_\_ 0079 \_\_

5080 (2) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0080 \_\_ 0081 \_\_ 0082 \_\_

5083 (3) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0083 \_\_ 0084 \_\_ 0085 \_\_

5086 (4) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0086 \_\_ 0087 \_\_ 0088 \_\_

5089 (5) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0089 \_\_ 0090 \_\_ 0091 \_\_

5092 (6) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0092 \_\_ 0093 \_\_ 0094 \_\_

5095 (7) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0095 \_\_ 0096 \_\_ 0097 \_\_

5098 (8) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0098 \_\_ 0099 \_\_ 0100 \_\_

5101 (9) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0101 \_\_ 0102 \_\_ 0103 \_\_

5104 (10) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0104\_\_ 0105 \_\_ 0106 \_\_

**Codes for grade levels of students**

PK Prekindergarten 07 7th grade

KG Kindergarten 08 8th grade

01 1st grade 09 9th grade

02 2nd grade 10 10th grade

03 3rd grade 11 11th grade

04 4th grade 12 12th grade

05 5th grade UG Ungraded

06 6th grade

Table 2. Major Fields of Study Codes

For questions 23d, 23f, 25d, and 26b

# General Education

## Elementary Education

101 Early childhood or Pre-K, general

102 Elementary grades, general

## Secondary Education

103 Middle grades, general

104 Secondary grades, general

## Special Education 

110 Special education, any

## Other Education

131 Administration

132 Counseling and guidance

133 Educational psychology

134 Policy studies

135 School psychology

136 Other non-subject matter specific education

# Subject Matter Specific

## Arts and Music 

141 Art or arts or crafts

142 Art history

143 Dance

144 Drama or theater

145 Music

## English and Language Arts 

151 Communications

152 Composition

153 English

154 Journalism

155 Language arts

156 Linguistics

157 Literature or literary criticism

158 Reading

159 Speech

## English as a Second Language

160 ESL or bilingual education: general

161 ESL or bilingual education: Spanish

162 ESL or bilingual education: other languages

## Foreign Languages

171 French

172 German

173 Latin

174 Spanish

175 Other foreign language

## Health Education

181 Health education

182 Physical education

## Mathematics and Computer Science

## 190 Mathematics

197 Computer science

## 

## Natural Sciences

211 Biology or life sciences

212 Chemistry

213 Earth sciences

214 Engineering

217 Physics

218 Other natural sciences

## 

## Social Sciences

221 Anthropology

222 Area or ethnic studies (excluding Native American Studies)

223 Criminal justice

224 Cultural studies

225 Economics

226 Geography

227 Government or civics

228 History

229 International studies

230 Law

231 Native American studies

232 Political science

233 Psychology

234 Sociology

235 Other social sciences

## 

## Vocational, Career, or Technical Education 

241 Agriculture and natural resources

242 Business management

243 Business support

244 Marketing and distribution

245 Health occupations

246 Construction trades, engineering, or science technologies (including
CADD and drafting)

247 Mechanics and repair

249 Manufacturing or precision production (electronics, metalwork,
textiles, etc.)

250 Communications and related technologies (including design, graphics
or printing; not including computer science)

253 Personal and public services (including culinary arts, cosmetology,
child care, social work, protective services, custodial services, and
interior design)

254 Family and consumer sciences education

255 Industrial arts or technology education

256 Other vocational, career, or technical education

## Miscellaneous

261 Architecture

263 Humanities or liberal studies

264 Library or information science

265 Military science or ROTC

266 Philosophy

267 Religious studies, theology or divinity

## Other

268 Other

# III. EDUCATIONAL BACKGROUND

23a. Do you have a bachelor's degree?

*\*If you have more than one bachelor's degree, information about
additional degrees will be asked in item 26a.*

0116 \_\_Yes

\_\_No à GO TO item 26a \[on page \# related to item 26a/below\].

**b. In what year did you receive your bachelor's degree?**

0117 /\_\_/\_\_/\_\_/\_\_/ Year

**c. Was this degree awarded by a university's Department or College of
Education, or a college's Department or School of Education?**

0118 \_\_Yes

> \_\_No

**d. What was your major field of study?**

*\*Record the field of study code and the field name from Table 2 \[on
page \# related to Table 2\].*

0119 Code /\_\_/\_\_/\_\_/ 5119
Major\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**e. Did you have a second major field of study?**

0120 \_\_Yes

\_\_No à GO TO item 24a \[on page \# related to item 24a/below\].

**f. What was your second major field of study?**

*\*Record the field of study code and the field name from Table 2 \[on
page \# related to Table 2\].*

0121 Code /\_\_/\_\_/\_\_/ 5121
Major\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**24. What is the name of the college or university where you earned
this degree?**

**a. Name of college or university**

9002
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\. In what city and state is it located?

9003 City
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 9004
State\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

0122 \_\_ Located outside the United States

25a. Do you have a master's degree?

*\*If you have more than one master's degree, information about
additional degrees will be asked in item 26a.*

0123 \_\_Yes

\_\_No à GO TO item 26a \[on page \# related to item 26a/below\].

a.  **In what year did you receive your master's degree?**

0124 /\_\_/\_\_/\_\_/\_\_/ Year

**c. Was this degree awarded by a university's Department or College of
Education, or a college's Department or School of Education?**

0125 \_\_Yes

> \_\_No

**d. What was your major field of study?**

*\*Record the field of study code and the field name from Table 2 \[on
page \# related to Table 2\].*

0126 Code /\_\_/\_\_/\_\_/ 5126
Major\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**26a. Have you earned any of the degrees or certificates listed
below?**

0127 \_\_Yes

\_\_No à GO TO item 27 \[on page \# related to item 27/below\]

**a. Degree b What was your major field of c. Was this degree awarded by
a d. In what year?**

**study for each degree?** **university's Department or College**

\*Record the field of study code and **of Education, or a college's
Department**

the field name from Table 2 \[on page \# **or School of Education?**

related to Table 2\].

\(1\) Vocational Code Major field of study title Year

certificate 0128 /\_/\_/\_/ 5128
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0129 \_\_\_\_

\(2\) Associate's Code Major field of study title Year

degree 0130 /\_/\_/\_/ 5130
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0131 \_\_\_\_

\(3\) SECOND Code Major field of study title 0133 \_Yes Year

Bachelor's degree 0132 /\_/\_/\_/ 5132
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_No 0134 \_\_\_\_

\(4\) SECOND Code Major field of study title 0136_Yes Year

Master's degree 0135 /\_/\_/\_/ 5135
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_No 0137\_\_\_\_\_

#  

\(5\) Educational specialist Code Major field of study title Year

or professional diploma 0138 /\_/\_/\_/
5138\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0139 \_\_\_\_\_

(at least one year beyond

a master's level)

\(6\) Certificate of Code Major field of study title Year

Advanced Graduate 0140 /\_/\_/\_/
5140\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ 0141 \_\_\_\_\_

Studies

\(7\) Doctorate or first Code Major field of study title 0143_Yes Year

professional degree 0142 /\_/\_/\_/
5142\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_No 0144 \_\_\_\_

(Ph.D Ed.D, M.D.,

L.L.B, J.D., D.D.S.)

**27. Did any of your coursework result in a concentration or
specialization in READING?**

NEW \_\_Yes

\_\_No

**28. Have you taken any of the following tests?**

*\*Mark (X) only one box.*

a.  **The Praxis I Pre-Professional Skills Test (PPST) in Reading**

> (The Praxis was formerly called the National Teachers Exam \[NTE\].)
>
> 0145 **\_**Taken and passed
>
> \_Taken and have not yet passed
>
> \_Not taken

a.  **The Praxis I Pre-Professional Skills Test (PPST) in Mathematics**

> (The Praxis was formerly called the National Teachers Exam \[NTE\].)
>
> 0146 **\_**Taken and passed
>
> \_Taken and have not yet passed
>
> \_Not taken

b.  **The Praxis I Pre-Professional Skills Test (PPST) in Writing**

> (The Praxis was formerly called the National Teachers Exam \[NTE\].)
>
> 0147 **\_**Taken and passed
>
> \_Taken and have not yet passed
>
> \_Not taken

c.  **The Praxis II: Subject Assessment in a specific content area**

> (The Praxis was formerly called the National Teachers Exam \[NTE\].)
>
> 0148 **\_**Taken and passed
>
> \_Taken and have not yet passed
>
> \_Not taken

d.  **Another test of basic skills or subject knowledge, other than
    those listed above, required by your school**

> 0150 **\_**Taken and passed
>
> \_Taken and have not yet passed
>
> \_Not taken

29\. Have you ever taken any graduate or undergraduate courses that
focused on teaching methods or teaching strategies?

*\*Include courses you have taken to earn a degree and courses taken
outside a degree program.*

*\*Do not include student teaching.*

0156 \_\_Yes  0157 How many courses? *Mark (X) only one box.*

> \_\_1 or 2 courses
>
> \_\_3 or 4 courses
>
> \_\_5 to 9 courses
>
> \_\_10 or more courses
>
> \_\_No [ GO TO item 30 \[on page \# related to item
> 30/below\].]{.mark}

**30. How long did your practice teaching last?**

*\*Mark (x) only one box.*

0155 \_\_ I had no practice teaching

> \_\_ 4 weeks or less
>
> \_\_ 5-7 weeks
>
> \_\_ 8-11 weeks
>
> \_\_12 weeks or more

31\. Did you enter teaching through an alternative certification
program?

(An alternative program is a program that was designed to expedite the
transition of non-teachers to a teaching career, for example, a state,
district or university alternative program.)

NEW \_\_Yes

\_\_No

**32a. Are you certified by the National Board for Professional Teaching
Standards in at least one content area?**

(The National Board for Professional Teaching Standards is a
nongovernment organization that administers National Board
certification, a voluntary national assessment program that certifies
teachers who meet high professional standards. In order to gain
certification, the candidate must at least complete a portfolio of
classroom practice and pass one or more tests of content knowledge.)

NEW \_\_Yes, fully certified à GO TO item 33 \[on page \# related to
item 33/below\].

\_\_No

**b. Are you working toward National Board Certification?**

NEW \_\_Yes

\_\_No

Table 3. Certification Content Area Codes

For questions 33 and 34

[Forms design: this table needs to fit on one page.]{.mark}

**General Education**

# 

## Elementary Education

101 Early childhood or Pre-K, general

102 Elementary grades, general

103 Middle grades, general

## Secondary Education

103 Middle grades, general

104 Secondary grades, general

## Special Education

111 Special education, general

112 Autism

113 Deaf and hard-of-hearing

114 Developmentally delayed

# [This also needs to be centered, like GE above:]{.mark} Subject Matter Specific

## 

## Arts and Music 

141 Art or arts and crafts

143 Dance

144 Drama or theater

145 Music

## English and Language Arts

151 Communications

152 Composition

153 English

154 Journalism

155 Language arts

158 Reading

159 Speech

## English as a Second Language

160 ESL or bilingual education: general

161 ESL or bilingual education: Spanish

162 ESL or bilingual education: other languages

## Foreign Languages

171 French

172 German

173 Latin

174 Spanish

175 Other foreign language

## Health Education

181 Health education

182 Physical education

## Mathematics and Computer Science

190 Mathematics

197 Computer science

## Natural Sciences 

210 Science, general

211 Biology or life sciences

212 Chemistry

213 Earth sciences

## 

## Special Education *(continued)*

115 Early childhood special education

116 Emotionally disturbed or behavior disorders

117 Learning disabilities

118 Mentally retarded

119 Mildly or moderately disabled

120 Orthopedically impaired

121 Severely or profoundly disabled

122 Speech or language impaired

123 Traumatically brain-injured

124 Visually impaired

125 Other special education

216 Physical science

**Natural Sciences** *(continued)*

217 Physics

218 Other natural sciences

## Social Sciences

220 Social studies, general

221 Anthropology

225 Economics

226 Geography

227 Government or civics

228 History

231 Native American studies

233 Psychology

234 Sociology

235 Other social sciences

## 

## Vocational, Career, or Technical Education

241 Agriculture and natural resources

242 Business management

243 Business support

244 Marketing and distribution

245 Health occupations

246 Construction trades, engineering, or science technologies (including
CADD and drafting)

247 Mechanics and repair

249 Manufacturing or precision production (electronics, metalwork,
textiles, etc.)

250 Communications and related technologies (including design, graphics
or printing; not including computer science)

253 Personal and public services (including culinary arts, cosmetology,
child care, social work, protective services, custodial services, and
interior design)

254 Family and consumer sciences education

255 Industrial arts or technology education

256 Other vocational, career, or technical education

## Miscellaneous

262 Driver education

263 Humanities or Liberal studies

264 Library or Information science

265 Military science or ROTC

266 Philosophy

267 Religious studies, theology or divinity

## Other

268 Other

[Forms design: these (264 -- 268) need to be right aligned under
"Miscellaneous".]{.mark}

# IV: CERTIFICATION AND TRAINING 

**33a. Do you currently hold regular or full certification by an
accrediting or certifying body OTHER THAN THE STATE?**

*\*Information about state-granted certification will be asked in item
34.*

0421 \_\_Yes

\_\_No GO TO item 34 \[on page \# related to item 34/below\].

**b. Using Table 3 on page 16, in what content area(s) does the teaching
certificate marked above allow you to each?**

(For some teachers the content area may be the grade level, e.g.,
elementary general, secondary general, etc.).

*\*Please record the content area code from Table 3 on page #.*

**1)** Code 0422 \_\_\_\_\_\_\_ Content Area
5422\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**c. Does the certificate marked in item 33a allow you to teach in
additional content areas?**\_\_

NEW \_\_Yes  GO TO item 33d \[on page \# related to item 33d/below\].

\_\_No GO TO item 34 \[on page \# related to item 34/below\].

**d. In what ADDITIONAL content area does the certificate marked in item
30a allow you to teach?**

(For some teachers the content area may be the grade level, e.g.,
elementary general, secondary general, etc.).

*\*Please record the content area code from Table 3 on page #.*

**1)** Code NEW \_\_\_\_\_\_\_ Content Area
NEW\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**e. Does the certificate marked in item 33a allow you to teach in
additional content areas?**

NEW \_\_Yes  GO TO item 33f \[on page \# related to item 33f/below\].

\_\_No GO TO item 34 \[on page \# related to item 34/below\].

**f. In what ADDITIONAL content area does the certificate marked in item
30a allow you to teach?**

(For some teachers the content area may be the grade level, e.g.,
elementary general, secondary general, etc.).

*\*Please record the content area code from Table 3 on page #.*

**1)** Code NEW \_\_\_\_\_\_\_ Content Area
NEW\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**g. Does the certificate marked in item 33a allow you to teach in
additional content areas?**

NEW \_\_Yes  GO TO item 33h \[on page \# related to item 33h/below\].

\_\_No GO TO item 34 \[on page \# related to item 34/below\].

**h. In what ADDITIONAL content area does the certificate marked in item
30a allow you to teach?**

(For some teachers the content area may be the grade level, e.g.,
elementary general, secondary general, etc.).

*\*Please record the content area code from Table 3 on page #.*

**1)** Code NEW \_\_\_\_\_\_\_ Content Area
NEW\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**i. Does the certificate marked in item 33a allow you to teach in
additional content areas?**

NEW \_\_Yes  GO TO item 33j \[on page \# related to item 33j/below\].

\_\_No GO TO item 34 \[on page \# related to item 34/below\].

**j. In what ADDITIONAL content area does the certificate marked in item
30a allow you to teach?**

(For some teachers the content area may be the grade level, e.g.,
elementary general, secondary general, etc.).

*\*Please record the content area code from Table 3 on page #.*

**1)** Code NEW \_\_\_\_\_\_\_ Content Area
NEW\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**34a. Do you have a current teaching certificate in THIS state?**

0187 \_\_Yes

\_\_No  GO TO item 36 \[on page \# related to item 36/below\].

**b. Which of the following describes the teaching certificate you
currently hold in this state?**

*\*Mark (X) only one box.*

0188 \_\_Regular or standard state certificate or advanced professional
certificate

\_\_Certificate issued after satisfying all requirements except the
completion of a probationary

period

\_\_Certificate that requires some additional coursework, student
teaching, or passage of a test

before regular certification can be obtained

> \_\_Certificate issued to persons who must complete a certification
> program in order to continue
>
> teaching
>
> \_\_ I do not have any of the above certifications in THIS state.

c.  **Using Table 3 \[on page \# related to Table 3\], in what content
    area(s) does the teaching certificate, marked in 34b above allow you
    to teach in THIS state?**

(For some teachers the content area may be the grade level \[e.g.,
Elementary general, secondary general, etc\].)

*\*If this certificate allows you to teach in more than one content
area, you may report additional content areas in later items.*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

d.  **Does the certificate marked in item 34b allow you to teach in
    additional content areas?**

NEW \_\_Yes à GO TO item 34e \[on page \# related to item 34e/below\].

\_\_No à GO TO item 36 \[on page \# related to item 36/below\].

e.  **In what ADDITIONAL content area does the certificate marked in
    item 34b allow you to teach?**

(For some teachers the content area may be the grade level, for example,
elementary general, secondary general, etc.)

*\*Please record the content area code from Table 3\[on page \# related
to Table 3\].*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

f.  **Does the certificate marked in item 34b allow you to teach in
    additional content areas?**

NEW \_\_Yes à GO TO item 34g \[on page \# related to item 34g/below\].

\_\_No à GO TO item 36 \[on page \# related to item 36/below\].

**g. In what ADDITIONAL content area does the certificate marked in item
34b allow you to teach?**

(For some teachers the content area may be the grade level, for example,
elementary general, secondary general, etc.)

*\*Please record the content area code from Table 3\[on page \# related
to Table 3\].*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**h. Does this certificate marked in item 34b allow you to teach in
additional content areas?**

NEW \_\_Yes à GO TO item 34i \[on page \# related to item 34i/below\].

\_\_No à GO TO item 36 \[on page \# related to item 36/below\].

**i. In what ADDITIONAL content area does the certificate marked in item
34b allow you to teach?**

(For some teachers the content area may be the grade level, for example,
elementary general, secondary general, etc.)

*\*Please record the content area code from Table 3\[on page \# related
to Table 3\].*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**j. Does this certificate marked in item 34b allow you to teach in
additional content areas?**

NEW \_\_Yes à GO TO item 34k \[on page \# related to item 34k/below\].

\_\_No à GO TO item 36 \[on page \# related to item 36/below\].

**k. In what ADDITIONAL content area does the certificate marked in item
34b allow you to teach?**

(For some teachers the content area may be the grade level, for example,
elementary general, secondary general, etc.)

*\*Please record the content area code from Table 3\[on page \# related
to Table 3\].*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**35a. Do you have another current teaching certificate in THIS state?**

0187 \_\_Yes

\_\_No  GO TO item 36 \[on page \# related to item 36/below\].

**b. Which of the following describes the teaching certificate you
currently hold in this state?**

*\*Mark (X) only one box.*

NEW \_\_Regular or standard state certificate or advanced professional
certificate

\_\_Certificate issued after satisfying all requirements except the
completion of a probationary

period

\_\_Certificate that requires some additional coursework, student
teaching, or passage of a test

before regular certification can be obtained

> \_\_Certificate issued to persons who must complete a certification
> program in order to continue
>
> teaching

**c. Using Table 3 \[on page \# related to Table 3\], in what content
area(s) does the teaching certificate, marked in 35b above allow you to
teach in THIS state?**

(For some teachers the content area may be the grade level \[e.g.,
Elementary general, secondary general, etc\].)

*\*If this certificate allows you to teach in more than one content
area, you may report additional content areas in later items.*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**d. Does the certificate marked in item 35b allow you to teach in
additional content areas?**

NEW \_\_Yes à GO TO item 34e \[on page \# related to item 34e/below\].

\_\_No à GO TO item 36 \[on page \# related to item 36/below\].

**e. In what ADDITIONAL content area does this other current teaching
certificate (described above in this item 35b) allow you to teach?**

(For some teachers the content area may be the grade level, for example,
elementary general, secondary general, etc.)

*\*Please record the content area code from Table 3\[on page \# related
to Table 3\].*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**f. Does the certificate marked in item 35b allow you to teach in
additional content areas?**

NEW \_\_Yes à GO TO item 34g \[on page \# related to item 34g/below\].

\_\_No à GO TO item 36 \[on page \# related to item 36/below\].

**g. In what ADDITIONAL content area does this other current teaching
certificate (described above in this item 35b) allow you to teach?**

(For some teachers the content area may be the grade level, for example,
elementary general, secondary general, etc.)

*\*Please record the content area code from Table 3\[on page \# related
to Table 3\].*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**h. Does this certificate marked in item 35b allow you to teach in
additional content areas?**

NEW \_\_Yes à GO TO item 34i \[on page \# related to item 34i/below\].

\_\_No à GO TO item 36 \[on page \# related to item 36/below\].

**i. In what ADDITIONAL content area does this other current teaching
certificate (described above in this item 35b) allow you to teach?**

(For some teachers the content area may be the grade level, for example,
elementary general, secondary general, etc.)

*\*Please record the content area code from Table 3\[on page \# related
to Table 3\].*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**j. Does this certificate marked in item 35b allow you to teach in
additional content areas?**

NEW \_\_Yes à GO TO item 34k \[on page \# related to item 34k/below\].

\_\_No à GO TO item 36 \[on page \# related to item 36/below\].

**k. In what ADDITIONAL content area does this other current teaching
certificate (described above in this item 35b) allow you to teach?**

(For some teachers the content area may be the grade level, for example,
elementary general, secondary general, etc.)

*\*Please record the content area code from Table 3\[on page \# related
to Table 3\].*

> **1)** Code NEW \_\_\_\_\_ Content Area NEW
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2) Which of the following grade ranges does this certificate apply
to?**

*\*Mark all that apply.*

*\*If your certificate does not restrict you to a specific grade
range(s) mark all three grade ranges.*

NEW \_\_ Early childhood, preschool and any of grades K-5

\_\_ Any of grades 6-8

\_\_ Any of grades 9-12

**36. Was your FIRST year of teaching before the 2007-08 school year?**

0209 \_\_Yes à GO TO item 40 \[on page \# related to item 40/below\].

\_\_No

**37. In your FIRST year of teaching, how well prepared were you to --**

\**If you are in your first year teaching, please answer for THIS school
year.*

*\*Mark (X) ONE box on each line.*

> **Not at all Somewhat Well Very Well**

**prepared prepared prepared prepared**

a.  **Handle a range of classroom**

> **management or discipline situations?** 0210

a.  **Use a variety of instructional**

> **methods?** 0211

b.  **Teach your subject matter?** 0212

c.  **Use computers in classroom**

**instruction?** 0213

d.  **Assess students?** 0214

e.  **Select and adapt curriculum**

> **and instructional materials?** 0215

**38. In your FIRST year teaching, did you participate in a teacher
induction program?**

*\*If you are in your first year teaching, please answer for THIS school
year.*

> 0216 \_Yes
>
> \_No

**39. Did you receive the following kinds of support during your FIRST
year of teaching?**

*\*If you are in your first year teaching, please answer for THIS school
year.*

a.  **Reduced teaching schedule or number of preparations**

> 0217 \_\_ Yes
>
> \_\_ No

a.  **Common planning time with teachers in your subject**

> 0219 \_\_ Yes
>
> \_\_ No

b.  **Seminars or classes for beginning teachers**

> 0220 \_\_ Yes
>
> \_\_ No

c.  **Extra classroom assistance (e.g., teacher aides)**

> 0221 \_\_ Yes
>
> \_\_ No

d.  **Regular supportive communication with your principal, other
    administrators, or**

> **department chair**
>
> 0222 \_\_Yes
>
> \_\_No
>
> **f. Ongoing guidance or feedback from a master or mentor teacher**
>
> 0226 **\_**\_Yes
>
> \_\_No

**V. PROFESSIONAL DEVELOPMENT**

**40. From the list of topics below, select the three that are your top
priorities for YOUR OWN additional professional development.**

---Student discipline and management

---Teaching students with special needs (e.g., disabilities, special
education)

---Teaching students with limited-English proficiency

---Use of technology in instruction

---The content of the subject(s) I primarily teach

---Content standards in the subject(s) I primarily teach

---Methods of teaching

---Student assessment

---Communicating with parents

---Other à Please specify below

9005
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**\*Enter the appropriate code (1-9) for each priority.**

> 0269 \_\_\_First priority
>
> 0270 \_\_ Second priority
>
> 0271 \_\_ Third priority

# 41. In the past 12 months, did you participate in any of the following professional development activities? 

> **a. University course(s) related to teaching**
>
> 0235 \_\_Yes à If "Yes", **How many?** 0236 /\_\_/\_\_/
>
> \_\_No
>
> **b. Observational visits to other schools**
>
> 0237 \_\_Yes à If "Yes", **How many?** 0238 /\_\_/\_\_/
>
> \_\_No
>
> **c. Workshops, conferences or training sessions in which you were a
> presenter**
>
> 0239 \_\_Yes à If "Yes", **How many?** 0240 /\_\_/\_\_/
>
> \_\_No
>
> **d. Other workshops, conferences or training sessions in which you
> were NOT a presenter**
>
> 0241 \_\_Yes à If "Yes", **How many?** 0242 /\_\_/\_\_/
>
> \_\_No

**42a. In the past 12 months, have you participated in any professional
development activities specific to and concentrating on the content of
the subject(s) you teach?**

> 0243 \_Yes
>
> \_No à GO TO item 43a \[on page \# related to item 43a/below\].

**b. In the past 12 months, how many hours did you spend on these
activities?**

*\*Mark (X) only one box.*

0244 \_\_ 8 hours or less

\_\_ 9-16 hours

\_\_ 17-32 hours

\_\_ 33 hours or more

**c. Overall, how useful were these activities to you?**

*\*Mark (X) only one box.*

0245 \_\_ Not useful

\_\_ Somewhat useful

\_\_ Useful

\_\_ Very useful

**43a. In the past 12 months, have you participated in any professional
development activities that focused on uses of computers for
instruction?**

0246 \_Yes

\_No à GO TO item 44a \[on page \# related to item 44a/below\].

**b. In the past 12 months, how many hours did you spend on these
activities?**

*\*Mark (X) only one box.*

0247 \_\_ 8 hours or less

\_\_ 9-16 hours

\_\_ 17-32 hours

\_\_ 33 hours or more

**c. Overall, how useful were these activities to you?**

*\*Mark (X) only one box.*

0248 \_\_ Not useful

\_\_ Somewhat useful

\_\_ Useful

\_\_ Very useful

**44a. In the past 12 months, have you participated in any professional
development activities that focused on reading instruction?**

0249 \_Yes

\_No à GO TO item 45a \[on page \# related to item 45a/below\].

**b. In the past 12 months, how many hours did you spend on these
activities?**

*\*Mark (X) only one box.*

0250 \_\_ 8 hours or less

\_\_ 9-16 hours

\_\_ 17-32 hours

\_\_ 33 hours or more

**c. Overall, how useful were these activities to you?**

*\*Mark (X) only one box.*

0251 \_\_ Not useful

\_\_ Somewhat useful

\_\_ Useful

\_\_ Very useful

**45a. In the past 12 months, have you participated in any professional
development activities that focused on student discipline and management
in the classroom?**

0252 \_Yes

\_No à GO TO item 46a below. \[on page \# related to item 46a/below\].

**b. In the past 12 months, how many hours did you spend on these
activities?**

*\*Mark (X) only one box.*

0253 \_\_ 8 hours or less

\_\_ 9-16 hours

\_\_ 17-32 hours

\_\_ 33 hours or more

**c. Overall, how useful were these activities to you?**

*\*Mark (X) only one box.*

0254 \_\_ Not useful

\_\_ Somewhat useful

\_\_ Useful

\_\_ Very useful

**46a. In the past 12 months, have you participated in any training or
professional development on how to teach students with disabilities?**

0283 \_Yes

\_No à GO TO item 47a \[on page \# related to item 47a/below\].

**b. In the last 3 years, how many hours did you spend on these
activities?**

*\*Mark (X) only one box.*

NEW \_\_ 8 hours or less

\_\_ 9-16 hours

\_\_ 17-32 hours

\_\_ 33 hours or more

**c. Overall, how useful were these activities to you?**

*\*Mark (X) only one box.*

NEW \_\_ Not useful

\_\_ Somewhat useful

\_\_ Useful

\_\_ Very useful

47a. In the past 12 months, have you participated in any training or
professional development on how to teach limited-English proficient
students?

0285 \_Yes

\_No à GO TO item 48 \[on page \# related to item 48/below\].

**b. In the last 3 years, how many hours did you spend on these
activities?**

*\*Mark (X) only one box.*

NEW \_\_ 8 hours or less

\_\_ 9-16 hours

\_\_ 17-32 hours

\_\_ 33 hours or more

**c. Overall, how useful were these activities to you?**

*\*Mark (X) only one box.*

NEW \_\_ Not useful

\_\_ Somewhat useful

\_\_ Useful

\_\_ Very useful

**48. In the past 12 months, have you participated in any professional
development activities that focused on other topics not included in
42-48 above?**

0255 \_\_Yes à Please specify 5255
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_No

**VI. WORKING CONDITIONS**

49\. Including hours spent during the school day, before and after
school, and on the weekends, how many hours do you spend on ALL teaching
and other school-related activities during a typical FULL WEEK at THIS
school?

*\*Report to the nearest whole hour; do not record fractions of an hour
or minutes.*

0297 /\_\_/\_\_/\_\_/ Total weekly hours

**50. How many hours are you required to work to receive BASE PAY during
a typical FULL WEEK at THIS school?**

(This would be base contract hours, or the equivalent, NOT including
stipends or extra pay for extra duty.)

\*Report hours to the nearest whole hour; do not record fractions of an
hour or minutes.

0298 /\_\_/\_\_/\_\_/ Total weekly hours

**51. Of the total BASE PAY HOURS reported in item 50, how many hours a
week are you paid to deliver INSTRUCTION to a class of students in THIS
school?**

(Example: If your base contract requires you to work 40 hours a week and
30 of those hours are for delivering instruction and 10 hours are for
planning, monitoring students outside of class time, etc., you would
report 30 hours.)

*\*Report to the nearest whole hour; do not record fractions of an hour
or minutes.*

*\*"PULL-OUT" OR "PUSH-IN' TEACHERS: Please include the number of hours
you instruct individual students or small groups of students.*

0299 /\_\_/\_\_/\_\_/ Total weekly hours

**52. During this school year, do you or will you \-\--**

a.  **Coach a sport?**

> 0300 \_\_Yes

\_\_No

a.  **Sponsor any student groups, clubs, or organizations?**

> 0301 \_\_Yes

\_\_No

b.  **Serve as a department lead or chair?**

> 0302 \_\_Yes

\_\_No

c.  **Serve as a lead curriculum specialist?**

> 0303 \_\_Yes

\_\_No

d.  **Serve on a school-wide committee or task force?**

> 0304 \_\_Yes

\_\_No

**53. In the LAST SCHOOL YEAR how much of your own money did you spend
on classroom supplies, without reimbursement?**

*\*Please use your best estimate for costs incurred, in whole dollars.*

*\*If none, please mark (X) the box.*

> NEW \_\_None
>
> \$ /\_\_ /, \_\_/\_\_/\_\_/.00

**54. Do you use the following to communicate with parents or students
outside of the regular school day?**

**a. E-mail or list-serve to send out group updates or information**

NEW \_\_ Yes

\_\_ No

**b. E-mail to address individual questions or concerns**

NEW \_\_ Yes

\_\_ No

**c. Online bulletin board for class discussion**

NEW \_\_ Yes

\_\_ No

**d. Course or teacher web page**

NEW \_\_ Yes

\_\_ No

**e. Course or teacher blog**

(A blog is a type of website where entries are made, such as in a
journal or diary, usually displayed in a reverse chronological order.)

NEW \_\_ Yes

\_\_ No

**f. Real-time, typed "conversations" through instant messaging**

NEW \_\_ Yes

\_\_ No

**VII. SCHOOL CLIMATE AND TEACHER ATTITUDES**

**55. How much actual control do you have IN**

**YOUR CLASSROOM at this school over**

**the following areas of your planning and**

**teaching?**

*\*Mark (X) ONE box on each line.*

No Minor Moderate A great deal of

Control Control Control Control

**(a) Selecting textbooks and other instructional**

**materials** 0318 1\_\_\_ 2 \_\_\_ 3 \_\_\_ 4\_\_\_

**(b) Selecting content, topics, and skills**

**to be taught** 0319 1\_\_\_ 2 \_\_\_ 3 \_\_\_ 4\_\_\_

**(c) Selecting teaching techniques** 0320 1\_\_\_ 2 \_\_\_ 3 \_\_\_
4\_\_\_

**(d) Evaluating and grading students** 0321 1\_\_\_ 2 \_\_\_ 3 \_\_\_
4\_\_\_

**(e) Disciplining students** 0322 1\_\_\_ 2 \_\_\_ 3 \_\_\_ 4\_\_\_

**(f) Determining the amount of homework**

**to be assigned** 0323 1\_\_\_ 2 \_\_\_ 3 \_\_\_ 4\_\_\_

**56. To what extent do you agree or disagree with each of the following
statements?**

*\*Mark (x) one box on each line.*

Strongly Somewhat Somewhat Strongly

Agree Agree Disagree Disagree

> **a. The school administration's behavior**
>
> **toward the staff is supportive and**
>
> **encouraging.** 0331
>
> **b. I am satisfied with my teaching**
>
> **salary.** 0332
>
> **c. The level of student misbehavior in**
>
> **this school (such as noise, horseplay or**
>
> **fighting in the halls, cafeteria or student**
>
> **lounge) interferes with my teaching.** 0333
>
> **d. I receive a great deal of support**
>
> **from parents for the work I do.** 0334
>
> **e. Necessary materials such as textbooks,**
>
> **supplies, and copy machines are**
>
> **available as needed by the staff.** 0335
>
> **f. Routine duties and paperwork interfere**
>
> **with my job of teaching.** 0336
>
> **g. My principal enforces school rules for**
>
> **student conduct and backs me up when I need it.** 0337
>
> **h. Rules for student behavior are consistently**
>
> **enforced by teachers in this school, even for**
>
> **students who are not in their classes.** 0338

**i. Most of my colleagues share my**

> **beliefs and values about what the central**
>
> **mission of the school should be** 0339
>
> **j. The principal knows what kind of school\
> he/she wants and has communicated it to the staff.** 0340

**k. There is a great deal of cooperative effort among\
the staff members.** 0341

l**. In this school, staff members are recognized for a job**

**well done.** 0342

**m. I worry about the security of my job because of the**

**performance of my students on standardized tests.** 0343

**n. Content standards have had a positive\
influence on my satisfaction with teaching.** 0344

> **o. I am given the support I need to teach students with**

**special needs.** 0346

**p. The amount of student tardiness and class cutting in\
this school interferes with my teaching.** 0348

> **q. I am generally satisfied with being a teacher at this school.**
> 0350

57\. To what extent is each of the following a problem in this school?

> *\*Mark (x) one box on each line.*

Serious Moderate Minor Not a

Problem Problem Problem Problem

> **a. Student tardiness** 0364

**b. Student absenteeism** 0365

**c. Student class cutting** 0366

**d. Teacher absenteeism** 0367

> **e. Students dropping out** 0369
>
> **f. Student apathy** 0370
>
> **g. Lack of parent**
>
> **involvement** 0371
>
> **h. Poverty** 0372
>
> **i. Students come to school**
>
> **unprepared to learn** 0373
>
> **j. Poor student health** 0374

58\. To what extent do you agree or disagree with each of the following
statements?

*\*Mark (x) one box on each line.*

Strongly Agree Disagree Strongly

Agree Disagree

> **a. The stress and disappointments**
>
> **involved in teaching at this school**
>
> **aren\'t really worth it.** 0375
>
> **b. The teachers at this school like\
> being here; I would describe us as\
> a satisfied group.** 0376

**c. I like the way things are run at**

> **this school.** 0377
>
> **d. If I could get a higher paying job\
> I'd leave teaching as soon as**
>
> **possible.** 0378
>
> **e. I think about transferring to another\
> school.** 0379
>
> **f. I don't seem to have as much\
> enthusiasm now as I did when I\
> began teaching.** 0380

**g. I think about staying home from school\
because I'm just too tired to go.** 0381

**59a. If you could go back to your college days and start over again,
would you become a teacher or not?**

*\*Mark (x) only one box.*

*.*

0382 \_\_ Certainly would become a teacher

\_\_ Probably would become a teacher

\_\_ Chances about even for and against

\_\_ Probably would not become a teacher

\_\_ Certainly would not become a teacher

**b. How long do you plan to remain in teaching?**

*\*Mark (X) only one box.*

0383 \_\_ As long as I am able

\_\_ Until I am eligible for retirement benefits from this job

\_\_ Until I am eligible for retirement benefits from a previous job

\_\_ Until I am eligible for Social Security benefits

\_\_ Until a specific life event occurs (e.g., parenthood, marriage)

\_\_ Until a more desirable job opportunity comes along

\_\_ Definitely plan to leave as soon as I can

\_\_ Undecided at this time

**60a. Has a student FROM THIS SCHOOL ever threatened to injure you?**

0384 \_\_ Yes

\_\_ No à GO TO item 61a below.

b.  **Has a student FROM THIS SCHOOL threatened to injure you IN THE
    PAST 12 MONTHS?**

0385 \_\_ Yes

> \_\_ No à GO TO item 61a below.

b.  **In the past 12 months, how many times has a student FROM THIS
    SCHOOL threatened to injure you?**

0386 /\_\_/\_\_/ Times

**61a. Has a student FROM THIS SCHOOL ever physically attacked you?**

0387 \_\_ Yes

\_\_ No à GO TO item 62 on page \--.

**b. Has a student FROM THIS SCHOOL physically attacked you IN THE PAST
12 MONTHS?**

0388 \_\_ Yes

> \_\_ No à GO TO item 62 on page \-\--.

**c. In the past 12 months, how many times has a student FROM THIS
SCHOOL physically attacked you?**

0389 **/\_\_/\_\_/** Times

## VIII. GENERAL EMPLOYMENT INFORMATION AND BACKGROUND INFORMATION

**62. The following questions refer to your before-tax earnings from
teaching and other employment.**

**DURING THE SUMMER OF 2007, did you have any earnings from --**

*\*Please report in whole dollars.*

a.  **Teaching summer school in this or any other school?**

> 0393 \_Yes à How much? 0394 /\_\_/\_\_/,\_\_/\_\_/\_\_/.00
>
> \_No

b.  **Working in a non-teaching job in this or any other school?**

> 0395 \_Yes à How much? 0396 /\_\_/\_\_/,\_\_/\_\_/\_\_/.00
>
> \_No
>
> **c. Working in any NONSCHOOL job?**
>
> 0397 \_\_Yes à How much? /\_\_/\_\_/\_\_/,\_\_/\_\_/\_\_/.00
>
> \_\_No

**63.** **DURING THE CURRENT SCHOOL YEAR, what is your academic year
base teaching salary?**

*\*Please report in whole dollars.*

0399 /\_\_/\_\_/\_\_/,\_\_/\_\_/\_\_/.00

**64. DURING THE CURRENT SCHOOL YEAR, do you, or will you, earn any
additional compensation from this school for extracurricular or
additional activities such as coaching, student activity sponsorship, or
teaching evening classes?**

*\*Please report in whole dollars.*

0400 **\_\_**Yes à How much? 0401 /\_\_/\_\_/,\_\_/\_\_/\_\_/.00

\_\_No

**65. DURING THE CURRENT SCHOOL YEAR, have you earned income from any
OTHER school sources this year, such as a merit pay bonus, etc.?**

\*Do not report any earnings already reported.

\*Please report in whole dollars.

0402 **\_\_**Yes à How much? 0403 /\_\_/\_\_/,\_\_/\_\_/\_\_/.00

\_\_No

**66a. DURING THE CURRENT SCHOOL YEAR, do you, or will you, earn
additional compensation from working in any job OUTSIDE this school?**

\*Please report in whole dollars.

0404 **\_\_**Yes à How much? 0405 /\_\_/\_\_/,\_\_/\_\_/\_\_/.00

\_\_No à GO TO item 67 below.

**b. Which of these best describes this job OUTSIDE this school?**

\*Mark (X) only one box.

0406 \_\_Teaching or tutoring

\_\_Non-teaching, but related to teaching field

\_\_Other

**67. Do you work in this school on a contributed service basis, that
is, for less than full salary or for no salary, for example, as a member
of a religious order?**

0464 \_\_ Yes

\_\_ No

**68. Are you a member of a teachers' union or an employee association
similar to a union?**

0407 \_\_Yes

\_\_No

**69. Are you male or female?**

0408 \_Male

\_Female

**70. Are you of Hispanic or Latino origin?**

0409 \_Yes

\_No

**71a. What is your race?**

*\*Mark (X) one or more races to indicate what you consider yourself to
be.*

\_\_ White

0411 \_\_ Black or African-American

0412 \_\_ Asian

0413 \_\_ Native Hawaiian or Other Pacific Islander

0414 \_\_ American Indian or Alaska Native GO TO Item 71b below.

**b. Are you enrolled in a state or federally recognized tribe?**

0415 \_\_Yes

\_\_No

**72. What is your year of birth?**

0416 /\_1\_/\_9\_/\_\_/\_\_/

**73. The survey you have completed may involve a brief follow-up at a
later time in order to gain information on teachers\' movements in the
labor force. The following information would assist us in contacting you
if you have moved or changed jobs.**

**Please PRINT your name, your spouse\'s name (if applicable), your home
address,**

**your telephone number, and the most convenient time to reach you.**

**a. Your name**

**b. Spouse's full name (if applicable)**

**c. Street address**

**d. City**

**e. State**

**f. ZIP code+4**

**g. Home telephone**

AREA CODE TELEPHONE NUMBER

/\_\_/\_\_/\_\_/ - /\_\_/\_\_/\_\_/ - /\_\_/\_\_/\_\_/\_\_/

**h. (NEW) Work e-mail address**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**i. (NEW) Home e-mail address**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**j. In whose name is the telephone number listed?**

*\*Mark (X) only one box.*

\_\_ My name

\_\_ Other à Specify name

Please PRINT the most convenient time to reach you.

**k.** Best day(s) to reach you

*\*Enter Mon, Tue, etc., as appropriate.*

Days

**l.** Best time of day to reach you

*\*Mark (X) only one box.*

\_\_ a.m.

\_\_ p.m.

**74. What are the names and addresses of two other people who would
know where to get in touch with you during the coming years? Please do
not list more than one person who now lives with you. Remember to record
the relationship of these persons to you (for example, parent, friend,
sister, cousin, etc.) in section b.**

**(1) First Person**

**a.** Name

**b.** Relationship to you

**c.** Street address

**d.** City

**e.** State

**f.** ZIP code + 4

**g. Home telephone**

AREA CODE TELEPHONE NUMBER

/\_\_/\_\_/\_\_/ - /\_\_/\_\_/\_\_/ - /\_\_/\_\_/\_\_/\_\_/

**h. (NEW) Work e-mail address**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**i. (NEW) Home e-mail address**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**j. In whose name is the telephone number listed?**

*\*Mark (X) only one box.*

\_\_ My name

\_\_ Other à Specify name

**What is the name and address of another person who would know where to
get in touch with you during the coming years? Remember to record the
relationship of this person to you (for example, parent, friend, sister,
cousin, etc.) in section b.**

**(2) Second Person**

**a.** Name

**b.** Relationship to you

**c.** Street address

**d.** City

**e.** State

**f.** ZIP code + 4

**g. Home telephone**

AREA CODE TELEPHONE NUMBER

/\_\_/\_\_/\_\_/ - /\_\_/\_\_/\_\_/ - /\_\_/\_\_/\_\_/\_\_/

**h. (NEW) Work e-mail address**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**i. (NEW) Home e-mail address**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**j. In whose name is the telephone number listed?**

*\*Mark (X) only one box.*

\_\_ My name

\_\_ Other à Specify name

**75. Please indicate how much time it took you to complete this form,
not counting interruptions.**

\*Please record the time in minutes, e.g. 50 minutes, 65 minutes, etc.

0417 /\_\_/\_\_/\_\_/ Minutes

**76. Please enter the date you complete this questionnaire.**

*\*Report month as a number, i.e., 01 for January, 02 for February,
etc.*

Month Day Year

0418 /\_\_/\_\_/ 0419 /\_\_/\_\_/ 0420 /\_\_/\_\_/\_\_/\_\_/