Explanation

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A B C

Worksheet Name Instrument

App A Spring 4th Child Quex Spring Fourth-Grade Child Questionnaire, Appendix A

App B Spring 4th Parent Interview Spring Fourth-Grade Parent Interview, Appendix B

App C Spring 4th TQ Spring Fourth-Grade Teacher Questionnaire, Appendix C

App D Spring 4th Reading TQC Spring Fourth-Grade Reading and Language Arts Teacher Questionanire, Appendix D

App D Spring 4th Math TQC Spring Fourth-Grade Mathematics Teacher Questionnaire, Appendix D

App D Spring 4th Science TQC Spring Fourth-Grade Science Teacher Questionnaire, Appendix D

App E Spring 4th SpEd A Spring Fourth-Grade Special Education Teacher Questionnaire A, Appendix E

App E Spring 4th SpEd B Spring Fourth-Grade Special Education Teacher Questionnaire B, Appendix E

App F Spring 4th School Adm A Spring Fourth-Grade School Administrator Questionnaire A, Appendix F

App F Spring 4th School Adm B Spring Fourth-Grade School Administrator Questionnaire B, Appendix F

This file contains a listing of every question asked of study children, parents, reading, math, and science teachers, 

special education teachers, and school administrators in the spring fourth grade data collection round (with the 

exception of the direct assessment items). For each question, the question wording is provided, along with the 

item source, the construct the item measures, and the specific research question in Part C of this OMB package for 

which the item is intended to provide information. 

Each worksheet in this file pertains to one instrument. The worksheet name notes the specific instrument, as well 

as the appendix within the OMB package in which the full instrument can be found. Below is a list of the worksheet 

name and a full description of the instrument to which the worksheet pertains. 

Page 1 of 1
Section Item #

Introduction CLQ400

CLQ401

CLQ402

Spring Fourth-Grade Child Questionnaire, Appendix H
CLQ403

School Liking CLQ405

CLQ410

CLQ415

CLQ420

CLQ425

Peer Relationships CLQ430

CLQ435, 

450, 470
CLQ440

CLQ445

CLQ455

CLQ460

CLQ465

CLQ475

CLQ480

CLQ485
CLQ486

CLQ487

CLQ488

CLQ489

Media Usage CLQ490

CLQ495
CLQ500

Pet Relationships CLQ505

CLQ510

CLQ515

CLQ520

CLQ525

CLQ530
CLQ535

CLQ540

CLQ545

CLQ547

CLQ549

CLQ550

CLQ555
Item Stem

PLUG HEADPHONES INTO THE COMPUTER. POSITION LAPTOP IN FRONT OF THE 

CHILD.

Now, you are going to use the computer to tell us a little more about yourself. The 

computer will read some sentences while you listen on the headphones. [HOLD UP 

HEADPHONES]

Then you will pick the answer that best describes you by touching your answer on the 

computer screen.

[TOUCH THE MIDDLE OF THE COMPUTER SCREEN WITH ONE FINGER]

You can change the volume by pressing this button [POINT TO THE RIGHT BUTTON 

ABOVE STICKER] to make it louder and this button [POINT TO THE LEFT BUTTON 

ABOVE STICKER] to make it softer. If you don't want the questions and answers read 

to you, just turn the volume all the way down.

SHOW THE CHILD HOW TO ADJUST THE SIZE OF THE HEADPHONES.

Okay, go ahead and put these headphones on and adjust them so they fit. Then, you 

will hear directions about what to do.

TURN LAPTOP AROUND. ROTATE LAPTOP SCREEN TO FACE THE CHILD.

Hello. Before you begin, please change the volume if this voice is too loud or too soft.

In a minute, sentences will appear on the screen, and they will be read to you along 

with a list of answers. For

these questions, there are no right or wrong answers, and all your answers are 

private. No one will be told

the answers that you pick.

To choose your answer, just touch it on the computer screen. You don't have to wait 

for the computer to

finish reading all the answers before you choose your answer.

If you want to change your answer, touch the "ERASE" button and then touch the 

new answer you want to

pick.

If you want to go back and change an answer, touch the "BACK" button to move to 

earlier screens.

If you have any questions, or if you need help adjusting the volume or the size of 

your headphones, please ask

for help now.

When you're ready to move on, please touch the "NEXT" button to move to the next 

screen.

Now let's practice. Touch the answer that best describes you, and then touch the 

"NEXT" button.

How often do you watch TV?

stionnaire, Appendix H
Great, thanks for practicing.

One last thing before you begin. If there is a question you do not want to answer, just 

touch the "NEXT" button to skip over it. If you touch the "NEXT" button without 

answering, the computer will ask you if you want to skip the question, just make sure 

you didn't skip the question by accident.

Please touch the "NEXT" button to move to the next screen.

Think about yourself and your experiences this school year. How often do the 

following things happen?

I try hard to do well in school.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

In class, I work as hard as I can.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

When I'm in class, I participate in class discussions.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

I pay attention in class.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

When I'm in class, I listen very carefully.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Kids in my class make me feel better if I'm having a bad day. 

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Social Distress. Items not included due to copyright restrictions (3 items total)

question.
I feel lonely at school.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Kids in my class let me play with them.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

I feel left out at school.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Kids in my class make me feel happy. 

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Kids in my class would help me if I hurt myself on the playground. 

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Kids in my class tell me that I'm their friend. 

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

I feel alone at school.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Kids in my class would help me if other kids were being mean to me. 

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.
Next, please think about experiences that you have had with other students. 

During this school year, how often have other students teased you, made fun of you, 

or called you names?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

During this school year, how often have other students told lies or untrue stories 

about you?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

During this school year, how often have other students pushed, shoved, slapped, hit, 

or kicked you?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

During this school year, how often have other students left you out from playing with 

them on purpose?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

How often do you send texts, messages, or emails using an app, cell phone, 

computer, iPad or tablet, or other electronic device?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Does your family have rules about who you can send texts, messages, or emails to? 

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.
Does your family have rules about when you can send texts, messages, or emails?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Do you have a pet?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Have you ever had a pet?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

How old were you when you got your first pet? If you can't remember exactly how 

old you were, please take your best guess.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

How many pets do you have right now?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

What kind of {pet/pets} do you have? You can choose more than one answer if you 

have more than one pet.

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Do you have a favorite pet?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.
Which pet is your favorite pet?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

How often do you spend time playing with {your pet/your favorite pet/any of your 

pets}?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

How often do you have {your pet/your favorite pet/any of your pets} near you when 

you do homework, study, read, or watch TV?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

When you feel bad or sad, how often do you go to {your pet/your favorite pet/any of 

your pets} to help you feel better?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Do you consider {your pet/your favorite pet/any of your pets} to be {a 

member/members} of your family?

Please pick an answer and then touch the "NEXT" button or just touch the "NEXT" 

button to skip this

question.

Thank you for working with me. You are done answering questions on the computer. 

Please take off the headphones now.

TAKE THE HEADPHONES FROM THE CHILD. UNPLUG HEADPHONES FROM COMPUTER.

TAKE THE LAPTOP FROM THE CHILD AND PLACE THE LAPTOP DIRECTLY IN FRONT OF 

YOU.

SAY: Thank you. Now we are going to do something else.

TOUCH THE "NEXT" BUTTON TO CONTINUE.
Source Construct Research Question

ECLS-K:2011 3rd Grade CQ (modified)

Introduction NA

ECLS-K:2011 3rd Grade CQ (modified)

Introduction NA

ECLS-K:2011 3rd Grade CQ (modified)

Introduction NA
ECLS-K:2011 3rd Grade CQ (modified)

Introduction NA

Skinner, Ellen A., Kindermann, T. A., 

and Furrer, C. J. (In press). 

Behavior 

engagement

C1

Skinner, Ellen A., Kindermann, T. A., 

and Furrer, C. J. (In press). 

Behavior 

engagement

C1

Skinner, Ellen A., Kindermann, T. A., 

and Furrer, C. J. (In press). 

Behavior 

engagement

C1

Skinner, Ellen A., Kindermann, T. A., 

and Furrer, C. J. (In press). 

Behavior 

engagement

C1

Skinner, Ellen A., Kindermann, T. A., 

and Furrer, C. J. (In press). 

Behavior 

engagement

C1

SECCYD (Vandell, using Ladd items) 

"Kids in My Class at School"

Peer social support C2

LaGreca and Stone (1993)

Also used in ECLS-K:2011 Spring 3rd 

grade CQ

Social distress C2, C3
Parker, J. G. and Asher, S. R. (1993). Loneliness C2, C3

SECCYD (Vandell, using Ladd items) 

"Kids in My Class at School"

Peer social support C2

Parker, J. G. and Asher, S. R. (1993). Loneliness C2, C3

SECCYD (Vandell, using Ladd items) 

"Kids in My Class at School"

Peer social support C2

SECCYD (Vandell, using Ladd items) 

"Kids in My Class at School"

Peer social support C2

SECCYD (Vandell, using Ladd items) 

"Kids in My Class at School"

Peer social support C2

Parker, J. G. and Asher, S. R. (1993). Loneliness C2, C3

SECCYD (Vandell, using Ladd items) 

"Kids in My Class at School"

Peer social support C2
Espelage and Holt (2001) (modified)

Also used in ECLS-K:2011 Spring 3rd 

grade CQ

Peer victimization C4

Espelage and Holt (2001) (modified)

Also used in ECLS-K:2011 Spring 3rd 

grade CQ

Peer victimization C4

Espelage and Holt (2001) (modified)

Also used in ECLS-K:2011 Spring 3rd 

grade CQ

Peer victimization C4

Espelage and Holt (2001) (modified)

Also used in ECLS-K:2011 Spring 3rd 

grade CQ

Peer victimization C4

Adapted from the PEW September 

Tracking Survey (2009) (modified)

Media usage C5

ECLS Media usage C5
ECLS Media usage C5

Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6

Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6

Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6

Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6

Adapted from Lexington Attachment 

to Pets Scale (LAPS) (John, Garrity, & 

Stallones 19922)

Pet relationships C6

Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6
Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6

Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6

Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6

Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6

Adapted from CENSHARE Pet Attachment Survey (Holcomb, Williams, & Richards, 1988)

Pet relationships C6

ECLS-K:2011 3rd Grade CQ (modified)

Closing NA

ECLS-K:2011 3rd Grade CQ (modified)

Closing NA
App B Spring 4th Parent Intervi

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A B C D E F

Section Item # Item Stem Source Construct Research Question

Introduction

INQ.005 {In the fall of 2010/In the spring of 2011/In the fall of 2011/In the spring of 2012/In the fall of 

2012/In the spring of 2013/In the spring of 2014}, we spoke with {NAME OF RESPONDENT} who 

took part in the Early Childhood Longitudinal Study, Kindergarten Class of 2010-2011 on {DATE 

OF LAST INTERVIEW}. Am I talking to the same person?

ECLS-K Introduction NA

INQ.010 May I please speak with {NAME OF PREVIOUS ROUND RESPONDENT}? ECLS-K Introduction NA

INQ.015 Are you the parent or guardian in this household who knows the most about {CHILD}'s care, 

education, and health?

NHES:2007 (modified) Introduction NA

INQ.020 May I please speak with the parent or guardian in the household who knows the most about 

{CHILD}'s care, education, and health?

NHES:2007 (modified) Introduction NA

INQ.025 May I please speak with a household member who is 18 or older and knows about {CHILD}'s care, 

education, and health?

NHES:2007 (modified) Introduction NA

INQ.030 May I have your name please? ECLS-K Introduction NA

INQ.060 [May I have your name, please?] ECLS-K Introduction NA

INQ.070 [May I have your name, please?] ECLS-K Introduction NA

INQ.080/080b (As I mentioned earlier), you and {CHILD} were selected to take part in the Early Childhood 

Longitudinal Study Kindergarten Class of 2010-2011, which is sponsored by the U.S. Department 

of Education, National Center for Education Statistics. I have some questions for you that ask 

about {CHILD}’s school and home experiences. The information I collect in this interview will be 

extremely valuable in understanding the development of children and how their school 

experiences can be improved.

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, except as required by law.

This call will be recorded for quality control purposes.

ECLS-K Introduction NA

Spring Fourth-Grade Parent Interview, Appendix H

Page 1 of 30
App B Spring 4th Parent Intervi

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A B C D E F

INQ.090/090b {In the fall of 2010/In the spring of 2011/In the fall of 2011/In the spring of 2012/In the fall of 

2012/In the spring of 2013/In the spring of 2014}, you took part in the Early Childhood 

Longitudinal Study Kindergarten Class of 2010-2011, which is sponsored by the U.S. Department 

of Education, National Center for Education Statistics. I have some questions for you that ask 

about {CHILD}’s school and home experiences since our last interview. The information I collect 

in this interview will be extremely valuable in understanding the development of young children 

and how their early school experiences can be improved.

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, except as required by law.

This call will be recorded for quality control purposes. 

ECLS-K Introduction NA

INQ.130 Before we begin the interview, I would like to verify some information. I have recorded {CHILD's 

FIRST, MIDDLE, AND LAST NAME} as {CHILD}'s full name. Is this correct? 

ECLS-K Introduction NA

INQ180 I have recorded that {CHILD}'s home address is...Is this still correct? ECLS-K Introduction NA

INQ190 What is {CHILD}'s home address? Introduction NA

INQ.200 I have recorded that {PHONE NUMBER} is {CHILD}'s family's current home phone number. Is this 

correct?

ECLS-K Introduction NA

INQ.205 {What is {CHILD}'s family's current home phone number?} ECLS-K Introduction NA

INQ.300 Next, I have a few questions about {CHILD}'s background. Was {CHILD} born in this country, that 

is, in any of the fifty states or the District of Columbia?

ECLS-K Country of origin for 

sample child

PQ1, PQ3

INQ.310/312OS In what country or territory was {CHILD} born? ECLS-K Country of origin for 

sample child

PQ1, PQ3

INQ.320 In what year did {CHILD} come to the United States to stay? ECLS-K Length of residence 

in U.S. for sample 

child

PQ1, PQ3

INQ.330 Is {CHILD} a U.S. citizen? ECLS-K Citizenship of child PQ1, PQ3

PIQ.130 Now I'd like to ask you about {CHILD}'s school. 

Since the beginning of this school year, have you or the other adults in your household attended 

an open house or a back-to-school night?

ECLS-K Parent participation 

in school activities

PQ5

PIQ.140 [Since the beginning of this school year, have you or the other adults in your household...] 

Attended a meeting of a PTA, PTO, or Parent-Teacher Organization?

ECLS-K Parent participation 

in school activities

PQ5

Page 2 of 30
App B Spring 4th Parent Intervi

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A B C D E F

PIQ.150 [Since the beginning of this school year, have you or the other adults in your household...] Gone 

to a regularly-scheduled parent-teacher conference with {CHILD}'s teacher or meeting with 

{CHILD}'s teacher?

ECLS-K Parent attendance at 

parent-teacher 

conferences and 

meetings

PQ5

PIQ.160 [Since the beginning of this school year, have you or the other adults in your household...] 

Attended a school or class event, such as a play, sports event, or science fair?

ECLS-K Parent participation 

in school activities

PQ5

PIQ.170 [Since the beginning of this school year, have you or the other adults in your household...] Served 

as a volunteer in {CHILD}’s classroom or elsewhere in the school?

NHES:2007 Parent participation 

in school activities

PQ5

PIQ.185 During this school year, how many times have you or other adults in your household gone to 

meetings or participated in activities at {CHILD}'s school?

ECLS-K Parent participation 

in school activities

PQ5

PIQ.495 Do you {or your spouse/partner} use a computer or any other electronic device to communicate 

with or get information from {CHILD}'s school?

ELS:2002 (modified)

Parent involvement 

online PQ5

PIQ.496a/b/c How often do you {or your spouse/partner} use a computer or any other electronic device in the 

following ways? Would you say never, less than once a year, once or twice a year, several times 

a year, at lease once a month, or weekly?

a. To communicate with {CHILD}'s teachers and administrative staff by email about {CHILD}, for 

example, about how {he/she} is performing, or about absences or tardiness?

b. To find out about homework and other school assignments and projects?

c. To find out about {CHILD}'s grades?

ELS:2002 (modified)

Parent involvement 

online PQ5

PIQ.510 How often does {CHILD} do homework at home? Would you say...

Never, 

Less than once a week, 

1 to 2 times a week, 

3 to 4 times a week, or 

5 or more times a week?

ECLS-K Frequency child does 

homework at home

PQ4, PQ5

Page 3 of 30
App B Spring 4th Parent Intervi

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A B C D E F

PIQ.520 During this school year, how often did you or someone else help {CHILD} with {CHILD}'s 

homework? Would you say...

Never, 

Less than once a week, 

1 to 2 times a week, 

3 to 4 times a week, or 

5 or more times a week?

ECLS-K:2011 Homework 

monitoring by 

parents

PQ4, PQ5

PIQ.550 How often do you check that {CHILD} has completed all homework? Would you say never, rarely, 

sometimes, or always?

ECLS-K Homework 

monitoring by 

parents

PQ4, PQ5

PIQ.560 Now I would like to ask you about {his/her} grades during this school year. Overall, across all 

subjects {he/she} takes at school, does {he/she} get... 

Mostly A's, 

Mostly B's, 

Mostly C's, 

Mostly D's and lower, or 

Does {his/her} school not give those grades?

NHES Grades received at 

school

PQ1, PQ2

PIQ.570 Would you describe {CHILD}'s work at school as...

Excellent, 

Above average, 

Average, 

Below average, or 

Failing?

NHES Grades received at 

school

PQ1, PQ2

PIQ.585 How often would you say that {CHILD}...

a. Makes up reasons to stay home from school? 

b. Seems to dread going to school?

c. Becomes upset when it's time to go to school in the morning?

d. Asks to stay home from school?

e. Complains about going to school?

Would you say almost never, rarely, sometimes, a lot, or almost always?

The School Liking and 

Avoidance Questionnaire 

(SLAQ) 

School avoidance PQ1, PQ2

Family Structure

FSQ.010 Now I have a few questions about your household. We have listed that (READ NAMES FROM 

MATRIX) lived in this household at the time of our last interview. 

As I read each person's name again, please tell me if he or she still lives in this household.

Does {NAME} still live in this household?

ECLS-K Household roster: 

current

PQ1, PQ3

Page 4 of 30
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A B C D E F

FSQ.015/015OS Why is {NAME} no longer living in this household? ECLS-K Household roster: 

former household 

member's status

PQ1, PQ3

FSQ020 {Other than the people I just asked about, is there anyone else currently living in this household? 

For example, anyone who has moved in or any babies born since our last interview? Please tell 

me the names and ages of all the other people who normally live here. Please do not include 

anyone staying here temporarily who usually lives somewhere else.}

{Now I have a few questions about your household. We have noted that you and {CHILD} 

currently live in this household. First I’d like to ask you some questions about yourself, then I’d 

like you to please tell me the names and ages of all the other people who normally live here. 

Please do not include anyone staying here temporarily who usually lives somewhere else.} 

ECLS-K Household roster: 

current

PQ1, PQ3

FSQ.025 ENTER LAST NAME OF {NAME}. ECLS-K Household roster: 

current

PQ1, PQ3

FSQ.030 How old {are you/is {NAME}}? ECLS-K Household roster: 

current

PQ1, PQ3

FSQ.040 CODE IF OBVIOUS. OTHERWISE, ASK: {Are you/Is {NAME} male or female?} ECLS-K Household roster: 

current

PQ1, PQ3

FSQ.045 CHECK HOUSEHOLD MATRIX. ECLS-K Household roster: 

current

PQ1, PQ3

FSQ.060 Have we missed anyone who usually lives here who is temporarily away from home or living in a 

dorm at school, or any babies or small children?

ECLS-K Household roster: 

current

PQ1, PQ3

FSQ.110 Do you have a spouse or partner who lives in this household? ECLS-K Marital status of the 

primary caretakers

PQ1, PQ3

FSQ.120 Who in the household is your spouse or partner? ECLS-K Marital status of the 

primary caretakers

PQ1, PQ3

FSQ.121 During our last interview with this household (or family), it was reported that you were {the 

girlfriend or female partner of {CHILD}’s parent or guardian}/the boyfriend or male partner of 

{CHILD}’s parent or guardian/the female guardian of {CHILD}/the male guardian of 

{CHILD}/{CHILD}’s relative, but not a guardian/not related to {CHILD}/{CHILD}'s {RELATIONSHIP}}. 

Has there been a change in your relationship to {CHILD}?

ECLS-K Change in family 

relationship of 

respondent to child

PQ1, PQ3

Page 5 of 30
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A B C D E F

FSQ.122 During our last interview with this household (or family), it was reported that {NAME OF 

SPOUSE/PARTNER} was {the girlfriend or female partner of {CHILD}’s parent or guardian/the 

boyfriend or male partner of {CHILD}’s parent or guardian/{CHILD}’s relative, but not a 

guardian/the female guardian of {CHILD}/the male guardian of {CHILD}/not related to 

{CHILD}/{CHILD}'s {RELATIONSHIP}}. Has there been a change in the relationship of {NAME OF 

SPOUSE/PARTNER} to {CHILD}?

ECLS-K Change in family 

relationship of 

spouse/partner to 

child

PQ1, PQ3

FSQ.130 What is {your/{NAME}'s} relationship to {CHILD}? ECLS-K Relationship of 

household member 

to child

PQ1, PQ3

FSQ.140 {Are you/Is {NAME}} {CHILD}'s...

Biological or birth mother,

Adoptive mother,

Step mother,

Foster mother or female guardian, or

Other female parent or guardian?

ECLS-K Relationship of 

household member 

to child

PQ1, PQ3

FSQ.150 {Are you/Is {NAME}} {CHILD}'s...

Biological or birth father,

Adoptive father,

Step father,

Foster father or male guardian, or

Other male parent or guardian?

ECLS-K Relationship of 

household member 

to child

PQ1, PQ3

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A B C D E F

FSQ.160 {Are you/Is {NAME}} {CHILD}'s...

Full sister,

Half sister,

Step sister,

Adoptive sister, or

Foster sister?

ECLS-K Relationship of 

household member 

to child

PQ1, PQ3

FSQ.170 {Are you/Is {NAME}} {CHILD}'s...

Full brother,

Half brother,

Step brother,

Adoptive brother, or

Foster brother?

ECLS-K Relationship of 

household member 

to child

PQ1, PQ3

FSQ.180/181 {Are you/Is {NAME}} {CHILD}'s...

CODE NON-RELATIVE RELATIONSHIP BELOW IF MORE DESCRIPTIVE.

ECLS-K Relationship of 

household member 

to child

PQ1, PQ3

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56

57

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A B C D E F

FSQ.190 {Are you/Is {NAME}} Hispanic or Latino? ECLS-K Ethnicity of child, 

parent figures, 

respondent and 

respondent's spouse 

(if no mother or 

father figures) 

PQ1, PQ3

FSQ.195 What is {your/{NAME}'s} race? You may name one or more races to indicate what {you/NAME} 

{consider/considers} {yourself/himself/herself} to be.

ECLS-K Race of child, parent 

figures, respondent 

and respondent's 

spouse (if no mother 

or father figures) 

PQ1, PQ3

FSQ.196a Though we may have asked you about {CHILD}'s ethnicity and race in the past, I do have a few 

more questions I'd like to ask about that now. Is {CHILD} a member of a Spanish, Hispanic, or 

Latino group?

ECLS-K Ethnicity of child, 

parent figures, 

respondent and 

respondent's spouse 

(if no mother or 

father figures) 

PQ1, PQ3

FSQ.196b Which of the following Spanish, Hispanic, or Latino groups best describes {CHILD}'s origin? Is 

{he/she}...

Mexican, Mexican American or Chicano,

Puerto Rican,

Cuban, or

Other Spanish/Hispanic/Latino group?

ECLS-K Ethnicity of child, 

parent figures, 

respondent and 

respondent's spouse 

(if no mother or 

father figures) 

PQ1, PQ3

FSQ.197a Is {CHILD} a member of an Asian group? ECLS-K Ethnicity of child, 

parent figures, 

respondent and 

respondent's spouse 

(if no mother or 

father figures) 

PQ1, PQ3

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60

61

62

63

64

A B C D E F

FSQ.197b Which of the following Asian groups best describes {CHILD}'s origin? Is {he/she}...

Asian Indian,

Chinese,

Filipino,

Japanese,

Korean,

Vietnamese,

Hmong, or

Other Asian?

ECLS-K Ethnicity of child, 

parent figures, 

respondent and 

respondent's spouse 

(if no mother or 

father figures) 

PQ1, PQ3

FSQ.198a Is {CHILD} a member of a Pacific Islander group? ECLS-K Ethnicity of child, 

parent figures, 

respondent and 

respondent's spouse 

(if no mother or 

father figures) 

PQ1, PQ3

FSQ.198b Which of the following Pacific Islander groups best describes {CHILD}'s origin? Is {he/she}...

Native Hawaiian,

Guamanian or Chamarro,

Samoan, or

Other Pacific Islander?

ECLS-K Ethnicity of child, 

parent figures, 

respondent and 

respondent's spouse 

(if no mother or 

father figures) 

PQ1, PQ3

FSQ.200a {FILL 1} currently married, separated, divorced, widowed, in a domestic partnership, or {FILL 2} 

never been married {FILL 3}?

ECLS-K Marital status of the 

primary caretakers

PQ1, PQ3

FSQ.200b See matrix. ECLS-K Marital status of the 

primary caretakers

NA

Home 

Environment, 

Activities, and 

Cognitive 

Stimulation

HEQ.010a/b/c/d/e

/f

Now I'd like to talk with you about {CHILD}'s activities with family members. In a typical week, 

how often do you or any other family members do the following things with {CHILD}? 

a. Tell stories to {CHILD}?

b. Help {CHILD} to do arts and crafts?

c. Play games or do puzzles with {CHILD}?

d. Talk about nature or do science projects with {CHILD}?

e. Play a sport or exercise together?

f. Practice reading, writing or working with numbers?

Would you say not at all, once or twice a week, 3-6 times a week, or every day?

ECLS-K:2011 Frequency of home 

activities with child

PQ4, PQ5

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67

68

69

A B C D E F

HEQ.210 In the past week, how often did {CHILD} read to {himself/herself} or to others outside of school? 

Would you say...

Never,

Once or twice a week,

3 to 6 times a week, or

Every day?

ECLS-K Frequency of reading 

activities with child

PQ2, PQ4

HEQ.215 Generally, how many minutes did {CHILD} read at each of these times? ECLS-K Frequency of reading 

activities with child

PQ2, PQ4

HEQ.225 In an average week, how often does {CHILD} use a home computer or other electronic device to 

play with programs that teach {him/her} something, like math or reading skills? Would you say...

Never,

Once or twice a week,

3 to 6 times a week, or

Every day?

ECLS-K:2011 (modified) Use of 

electronic/computer 

devices

PQ4

HEQ.226 Do you monitor how many hours {CHILD} spends online? ECLS-K:2011 Parental monitoring 

child's use of 

electronic/computer 

devices 

PQ4

HEQ.227 Do you monitor what {CHILD} looks at online, or what websites and accounts {CHILD} can join 

online? Include everything the child may look at online, such as websites, email, videos, movies, 

television shows, online games, chat rooms, and picture or social media sites such as Instagram, 

Vine, Snapchat, YouTube, Twitter, and Facebook.

ECLS-K:2011 Parental monitoring 

child's use of 

electronic/computer 

devices 

PQ4

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71

72

73

74

75

76

77

78

79

80

A B C D E F

HEQ.228 How many close friends does {CHILD} have? Robert Crosnoe from the 

ECLS-K:2011 Technical 

Review Panel (TRP)

Child's friends PQ1, PQ2

HEQ.229 What kind of influence is {CHILD}'s {best} friend? Would you say always a good influence, usually 

a good influence, neither a good nor a bad influence, usually a bad influence, or always a bad 

influence?

The National Longitudinal 

Study of Adolescent Health 

(Ad Health) (adapted)

Child's friends PQ1, PQ2

HEQ.280 Is {CHILD} tutored on a regular basis, by someone other than you or a family member, in a

specific subject, such as reading, math, science, or a foreign language?

ECLS-K Tutoring PQ5

HEQ.290/290OS What is {CHILD} tutored in? ECLS-K Tutoring PQ5

HEQ300 Outside of school hours in the past year, has {CHILD} participated in: Academic activities, like 

science, computers, math lab, or taking a class to learn a language other than English?

NHES 2007 (modified) Child activities 

outside of school 

hours

PQ4

HEQ.301 Did {he/she} specifically learn about math, science, or technology in any of those academic 

activities?

High School Longitudinal 

Study of 2009 (HSLS:2009) 

(adapted)

Child activities 

outside of school 

hours: STEM related

PQ4

HEQ305 As part of {CHILD}’s participation in that activity, did {he/she} ever take a field trip focused on 

science activities, for example to a science museum or center, a science lab, a planetarium, or a 

nature center?

NCES Child activities 

outside of school 

hours: science 

related field trips

PQ4

HEQ310 Outside of school hours in the past year, has {CHILD} participated in organized athletic activities, 

like basketball, soccer, baseball, or gymnastics?

ECLS-K Child activities 

outside of school 

hours

PQ4

HEQ320 [Outside of school hours in the past year, has {CHILD} participated in:] Organized clubs or 

recreational programs, like scouts?

ECLS-K Child activities 

outside of school 

hours

PQ4

HEQ325 As part of {CHILD}’s participation in that program, did {he/she} ever take a field trip focused on 

science activities, for example to a science museum or center, a science lab, a planetarium, or a 

nature center?

NCES Child activities 

outside of school 

hours: science 

related field trips

PQ4

HEQ330 Outside of school hours in the past year, has {CHILD} participated in music lessons, for example, 

piano, instrumental music, or singing lessons?

ECLS-K Child activities 

outside of school 

hours

PQ4

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83

84

85

86

87

88

89

90

A B C D E F

HEQ340 [Outside of school hours in the past year, has {CHILD} participated in:] Drama classes? ECLS-K Child activities 

outside of school 

hours

PQ4

HEQ350 [Outside of school hours in the past year, has {CHILD} participated in:] Art classes or lessons, for 

example, painting, drawing, or sculpture?

ECLS-K Child activities 

outside of school 

hours

PQ4

HEQ370 [Outside of school hours in the past year, has {CHILD} participated in:] Organized performing arts 

programs, such as children's choirs, dance programs, or theater performances?

ECLS-K Child activities 

outside of school 

hours

PQ4

HEQ.391 [Outside of school hours in the past year, has {CHILD} participated in:] Religious activities or 

instruction?

ECLS-K Child activities 

outside of school 

hours

PQ4

HEQ.393 Did {CHILD}’s participation in {academic activities/organized athletic activities/ organized clubs or 

recreational programs/music lessons/drama classes /art classes or lessons/organized performing 

arts programs/ religious activities or instruction/any of these activities} help to cover the hours 

when you needed adult supervision for {him/her}?

ECLS-K Whether child 

activities serve as 

child care

PQ6

HEQ.400 Now, I have a question about your neighborhood. How safe is it for children to play outside 

during the day in your neighborhood? Would you say it's...

Not at all safe, 

Somewhat safe, or 

Very safe?

ECLS-K:2011 Neighborhood safety PQ4

HEQ.600a/b

On an average school night, how many hours of sleep does {CHILD} get? 

Youth Risk Behavior Survey 

(YRBS)

Amount of sleep PQ4

Social Skills, 

Problem 

Behaviors, and 

Approaches 

Toward Learning

SSQ020 a/b/c/d (Copyrighted item)

a. (copyrighted item)

b. (copyrighted item)

c. (copyrighted item)

d. (copyrighted item)

Behavior Rating Inventory

of Executive Function (BRIEF)

Child's working 

memory

PQ1, PQ2

Child Care

CCQ.376 Sometimes children spend time caring for themselves, either at home or somewhere else, 

without an adult or older child responsible for them. Does {CHILD} spend time caring for 

{himself/herself} on a regular basis before or after school?

ECLS-K Time child spends in 

self-care

PQ6

CCQ.377 How many hours per week does {CHILD} take care of {himself/herself}? ECLS-K Time child spends in 

self-care

PQ6

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92

93

94

95

96

A B C D E F

Non-Resident 

Parents

NRQ.040 The next questions are about {CHILD}'s contact with {his/her} {biological/adoptive} 

{father/mother}.

[We understand that some of these questions may be difficult {for adoptive parents} to answer; 

however, these are standard questions we ask when a child does not live with {his/her} biological 

parents. Any information you can provide will be helpful.]

How long has it been since {CHILD} last had a visit, a phone call, a video call, an e-mail, a text or 

other electronic message, or received a card or letter from {his/her} {biological/adoptive} 

{father/mother}? Would you say...

Less than one month,

More than a month but less than a year,

More than a year, or

No contact since birth?

ECLS-K (modified) Current contact and 

nature of 

relationship with 

biological/adoptive 

parents no longer 

living in household

PQ1, PQ3, PQ4

NRQ.123 How many times have {CHILD} and {his/her} {biological/adoptive} {father/ mother} talked on the 

telephone or in a video call to each other, e-mailed, texted, or had some other type of contact 

that was not in person in the past 4 weeks?

ECLS-K (modified) Current contact and 

nature of 

relationship with 

biological/adoptive 

parents no longer 

living in household

PQ1, PQ3, PQ4

Country of 

Origin for NonResident 

Biological 

Parents

COQ.005/OS Now we'd like to ask {another question} about {CHILD}'s bilogical mother. {I know you 

mentioned that {CHILD}'s biological mother is deceased, and I am sorry for this loss. We 

understand that it may be hard to talk about those who are no longer living, but I was hoping I 

could ask a couple quick background questions about where she was from.} In what country was 

{his/her} biological mother born?

ECLS-K Country of origin for 

nonresident parents

PQ1, PQ3

COQ.010 How old was {CHILD’}’s biological mother when she first moved to {any of the fifty states in the 

United States or the District of Columbia /the United States}?

ECLS-K Country of origin for 

nonresident parents

PQ1, PQ3

COQ.020/OS Now we'd like to ask {another question} about {CHILD}'s bilogical father. {I know you mentioned 

that {CHILD}'s biological father is deceased, and I am sorry for this loss. We understand that it 

may be hard to talk about those who are no longer living, but I was hoping I could ask a couple 

quick background questions about where he was from.} In what country was {his/her} biological 

father born?

ECLS-K Country of origin for 

nonresident parents

PQ1, PQ3

COQ025 How old was {CHILD’}’s biological father when he first moved to {any of the fifty states in the 

United States or the District of Columbia /the United States}?

ECLS-K Country of origin for 

nonresident parents

PQ1, PQ3

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98

99

100

A B C D E F

DWQ070a/b/c/d/

e/f

Now I am going to read some additional statements. Please tell me whether each statement is 

never true for you, sometimes true for you, often true for you, or very often true for you.

a. Even if I am really busy, I make time to listen to {CHILD}. 

b. I discourage {CHILD} from talking about {his/her} worries because it upsets {him/her}.

c. I encourage {CHILD} to talk about {his/her} troubles. 

d. I encourage {CHILD} to tell me about {his/her} friends and activities. 

e. I encourage {CHILD} to express {his/her} opinions.

f. When I lose my patience with {CHILD}’s questions and demands, I just don’t listen to {CHILD} 

anymore.

ECLS-K Parent-child 

relationship: 

communication

PQ4

DWQ.075 How often do you argue with {CHILD}? Please include major arguments as well as minor 

arguments, such as over homework or chores. Would you say never, almost never, sometimes, 

often, or always?

NCES Time spent arguing 

with child

PQ4

DWQ077a/b/c The following are a number of statements about your family. Please tell me how often each 

typically occurs in your home.

a. You threaten to punish {CHILD} and then do not actually punish {him/her}. Would you say this 

occurs never, almost never, sometimes, often, or always?

b. {CHILD} talks you out of being punished after {he/she} has done something wrong.

c. You let {CHILD} out of punishment early, like li restricons earlier than you originally said? 

Short form of Alabama 

Parenting Questonnaire

Inconsistent 

Discipline

PQ4

DWQ.081a/b Now I’d like to ask some questions about the amount of time {CHILD} plays video games. We 

want you to include games played on systems like Playstation, Wii, or Xbox, or on handheld 

devices such as a Nintendo DS, Sony PSP, iPod, iPad, or cellphone, or games played on the 

computer. 

On any given weekday, how much time does {CHILD} spend playing video games? Please do not 

include time {CHILD} spends on the computer doing educational activities or homework.

 

ECLS-K (modified) Time child spent 

playing video games

PQ4

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102

103

104

105

106

107

108

109

110

111

A B C D E F

Child's Health 

and Well-Being

CHQ.010 Now we'd like to discuss {CHILD}'s health and well-being. How long has it been since {CHILD}'s

last visit to a dentist or dental hygienist for dental care?

ECLS-K:2011 Dental visits PQ1, PQ2

CHQ.020 How long has it been since {CHILD}'s last visit to a clinic, health center, hospital, doctor's office, or

other place for routine health care?

ECLS-K:2011 Doctor visits PQ1, PQ2

CHQ.021 Has {CHILD} had an ear infection since last spring? ECLS-K:2011 (modified) Ear infections since 

last spring

PQ1, PQ2

CHQ.022 Has {CHILD} had an ear ache since last spring? ECLS-K:2011 (modified) Ear aches since last 

spring

PQ1, PQ2

CHQ.023 Since last spring, how many times did a doctor, nurse, or other medical professional tell you that

{CHILD} had an ear infection?

ECLS-K:2011 (modified) Ear infections since 

last spring

PQ1, PQ2

CHQ.024/024OS How have {CHILD}’s {ear infections/ear aches} been treated by your doctor, nurse, or other

medical professional since last spring?

ECLS-K:2011 (modified) Ear infections/aches 

treatment since last 

spring

PQ1, PQ2

CHQ.025 Since last spring, have ear tubes been placed in the right ear, left ear, or both ears when your

child had surgery to place tubes in {his/her} ears?

IF NEEDED: Please consider all surgeries since last spring if {CHILD} had more than one to place

ear tubes.

ECLS-K:2011 (modified) Ear tubes since last 

spring

PQ1, PQ2

CHQ.026 Has a doctor, nurse, or other medical professional ever told you that {CHILD} has asthma? ECLS-K Asthma PQ1, PQ2

CHQ.027 Does {he/she} receive treatment for this condition? ECLS-K Asthma PQ1, PQ2

CHQ.060 In a typical week, on how many days does {CHILD} get exercise that causes rapid breathing,

perspiration, and a rapid heartbeat for 20 continuous minutes or more?

ECLS-K Exercise/physical 

activities

PQ1, PQ2

CHQ.095 For the next set of questions, please base your answer on how {CHILD} compares to other

children of the same age. {CHILD} is independent and takes care of {himself/herself} ...

Better than other children {his/her} age,

As well as other children,

Slightly less well than other children, or

Much less well than other children?

ECLS-K Behavioral 

comparison to peers: 

 Independence and 

ability to take care of 

him/herself

PQ1, PQ2

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113

114

115

116

117

118

119

A B C D E F

CHQ.100 Does {CHILD} pay attention...

Better than other children {his/her} age,

As well as other children,

Slightly less well than other children, or

Much less well than other children?

ECLS-K Behavioral 

comparison to peers: 

 Attention

PQ1, PQ2

CHQ.105 Does {CHILD} learn, think, and solve problems...

Better than other children {his/her} age,

As well as other children,

Slightly less well than other children, or

Much less well than other children?

ECLS-K Behavioral 

comparison to peers: 

Learn, think, solve 

problems

PQ1, PQ2

CHQ.106 Does {CHILD} show good coordination in moving {his/her} arms and legs? Would you say

{he/she} does this...

Better than other children {his/her} age,

As well as other children,

Slightly less well than other children, or

Much less well than other children?

ECLS-K Behavioral 

comparison to peers: 

Child's coordination

PQ1, PQ2

CHQ.107 Would you say {CHILD} behaves and relates to other children...

Better than other children {his/her} age,

As well as other children,

Slightly less well than other children, or

Much less well than other children?

ECLS-K (modified) Behavioral 

comparison to peers: 

 Relating to children

PQ1, PQ2

CHQ.108 Would you say {CHILD} behaves and relates to adults...

Better than other children {his/her} age,

As well as other children,

Slightly less well than other children, or

Much less well than other children?

ECLS-K:2011 Behavioral 

comparison to peers: 

 Relating to adults

PQ1, PQ2

CHQ.109 Thinking about {CHILD}'s overall activity level, would you say {he/she} is...

Less active than other children {his/her} age,

About as active,

Slightly more active, or

A lot more active than other children {his/her} age?

ECLS-K Behavioral 

comparison to peers: 

 Overall activity level

PQ1, PQ2

CHQ.110 Does {CHILD} have any emotional or psychological difficulties? ECLS-K:2011 Emotional and 

psychological 

difficulties

PQ1, PQ2

CHQ.111 Do you think this is a mild problem, a moderate problem, or a severe problem? ECLS-K:2011 Emotional and 

psychological 

difficulties

PQ1, PQ2

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121

122

123

124

125

126

A B C D E F

CHQ.115 {Since last spring has {CHILD}/Has {CHILD} ever} been evaluated by a professional because of an

issue with {independence and taking care of {himself/herself} {or}/paying attention {or}/learning,

thinking, and solving problems {or}/ coordination in moving {his/her} arms and legs {or}/behaving

and relating to other children {or}/ behaving and relating to adults {or}/{his/her} overall activity

level {or}/{his/her} emotional or psychological difficulties}?

ECLS-K:2011 Evaluation of 

disabilities and 

health conditions

PQ1, PQ2

CHQ.120 {Since last spring, have you obtained/Did you obtain} a diagnosis or diagnoses of a problem from 

a professional?

ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ.125/125OS What was the diagnosis or were the diagnoses? ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ126/126OS What type of autism spectrum disorder does {CHILD} have? Is it autism, Asperger's Disorder,

Pervasive Developmental Disorder, something else, or was it identified generally as Autism

Spectrum Disorder?

ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions: 

Autism spectrum 

disorder

PQ1, PQ2

CHQ.130/131 How old was {CHILD} when the first diagnosis of a problem related to {a learning 

disability/Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD)/a 

developmental delay/autism, Asperger’s disorder, Pervasive Developmental Disorder (PDD), or 

other autism spectrum disorder/dyslexia/dyscalculia/an intellectual disability, severe cognitive 

disability, or mental retardation/an orthopedic impairment/a serious emotional disturbance/a 

traumatic brain injury/a panic disorder/separation anxiety disorder/obsessive compulsive 

disorder/generalized anxiety disorder/an {other} anxiety disorder/bipolar 

disorder/depression/speech/a sensory deficit disorder/oppositional defiant disorder/{TEXT FROM 

OTHER

SPECIFY}} was made?

ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ.135a/b What was the month and year when the diagnosis was made? ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ.140 Is {CHILD} now taking any prescription medicine for the condition related to {his/her} {learning 

disability/Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder 

(ADHD)/developmental delay/autism, Asperger’s disorder, Pervasive Developmental Disorder 

(PDD), or other autism spectrum disorder/dyslexia/dyscalculia/intellectual disability, severe 

cognitive disability, or mental retardation/orthopedic impairment/serious emotional 

disturbance/traumatic brain injury/panic disorder/separation anxiety disorder/obsessive 

compulsive disorder/generalized anxiety disorder/{other} anxiety disorder/bipolar 

disorder/depression/speech problems/sensory deficit disorder/oppositional defiant 

disorder{TEXT FROM OTHER SPECIFY}}?

ECLS-K:2011 Prescription 

medications

PQ1, PQ2

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128

129

130

131

132

A B C D E F

CHQ.155 Is {CHILD} medicated for ADD or ADHD at school, at home, or both? ECLS-K:2011 Prescription 

medications

PQ1, PQ2

CHQ.173 How long has {CHILD} taken such prescription medicine for the condition related to {his/her} {a 

learning disability/Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder 

(ADHD)/a developmental delay/autism, Asperger’s disorder, Pervasive Developmental Disorder 

(PDD), or other autism spectrum disorder/dyslexia/dyscalculia/an intellectual disability, severe 

cognitive disability, or mental retardation/orthopedic impairment/ a serious emotional 

disturbance/a traumatic brain injury/a panic disorder/separation anxiety disorder/obsessive 

compulsive disorder/generalized anxiety disorder/an {other} anxiety disorder/bipolar 

disorder/depression/speech problems/a sensory deficit disorder/oppositional defiant 

disorder/{TEXT FROM OTHER SPECIFY}}, in total?

Less than one month,

Less than a year,

1 to 2 years,

3 to 4 years, or

5 years or more?

ECLS-K:2011 Prescription 

medications

PQ1, PQ2

CHQ.200 For the next question, please base your answer on how {CHILD} compares to other children of the

same age. Does {CHILD} pronounce words, communicate with and understand others...

Better than other children {his/her} age,

As well as other children,

Slightly less well than other children, or

Much less well than other children?

ECLS-K:2011 Communication: 

comparison to peers

PQ1, PQ2

CHQ.206e Since last spring, has {CHILD} had a problem with stuttering? ECLS-K:2011 Communication 

problems

PQ1, PQ2

CHQ.210 {Since last spring has {CHILD}/Has {CHILD} ever} been evaluated by a professional because of

{his/her} ability to communicate? 

ECLS-K Evaluation of 

communication 

problems

PQ1, PQ2

CHQ.215 Did you obtain a diagnosis or diagnoses of a problem related to {his/her} ability to communicate

from a professional?

ECLS-K Diagnoses for 

communication 

problems

PQ1, PQ2

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134

135

136

137

138

139

A B C D E F

CHQ.216 Which best describes {CHILD}’s hearing? If {CHILD} has a hearing aid or other assistive device,

please consider {his/her} hearing without the hearing aid or assistive device. Would you say

{CHILD} has...

excellent hearing,

good hearing,

a little trouble hearing,

moderate trouble hearing,

a lot of trouble hearing, or

is {CHILD} deaf?

ECLS-K Hearing ability PQ1, PQ2

CHQ.217 Please indicate whether the following statement describes {CHILD}'s hearing. If {CHILD} has a

hearing aid or other assistive device, please consider {his/her} hearing without the hearing aid or

assistive device. {CHILD} can usually hear and understand what a person says without seeing his

or her face if that person whispers to {him/her} from across a quiet room.

ECLS-K Hearing ability PQ1, PQ2

CHQ.218 [Please indicate whether the following statement describes {CHILD}'s hearing. If {CHILD} has a

hearing aid or other assistive device, please consider {his/her} hearing without the hearing aid or

assistive device.] {CHILD} can usually hear and understand what a person says without seeing his

or her face if that person talks in a normal voice to {him/her} from across a quiet room.

ECLS-K:2011 Hearing ability PQ1, PQ2

CHQ.219 [Please indicate whether the following statement describes {CHILD}'s hearing. If {CHILD} has a

hearing aid or other assistive device, please consider {his/her} hearing without the hearing aid or

assistive device.] {CHILD} can usually hear and understand what a person says without seeing his

or her face if that person shouts to {him/her} from across a quiet room.

ECLS-K:2011 Hearing ability PQ1, PQ2

CHQ.220 [Please indicate whether the following statement describes {CHILD}'s hearing. If {CHILD} has a

hearing aid or other assistive device, please consider {his/her} hearing without the hearing aid or

assistive device.] {CHILD} can usually hear and understand what a person says without seeing his

or her face if that person speaks loudly into {his/her} ears or better ear.

ECLS-K:2011 Hearing ability PQ1, PQ2

CHQ.221 Is {CHILD}’s hearing worse in one ear? ECLS-K:2011 Hearing ability PQ1, PQ2

CHQ.222 Which best describes {CHILD}'s hearing in {his/her} worse ear? If {CHILD} has a hearing aid or 

other assistive device, please consider {his/her} hearing without the hearing aid or assistive 

device.

In {his/her} worse ear, would you say {CHILD} has...

Excellent hearing,

Good hearing,

A little trouble hearing,

Moderate trouble hearing,

A lot of trouble hearing, or

is {CHILD} Deaf?

ECLS-K:2011 Hearing ability PQ1, PQ2

Page 19 of 30
App B Spring 4th Parent Intervi

140

141

142

143

144

145

146

147

A B C D E F

CHQ.235 {Besides the ECLS-K:2011 hearing evaluation done for this study, {Since last spring, has/Since the

spring of 2013, has/Since the fall of 2012, has/has}} / {Since last spring, has/Since the spring of

2013, has/Since the fall of 2012,

has/Has}} {CHILD}'s hearing {ever} been evaluated by a professional? .

ECLS-K (modified) Evaluated for 

hearing ability

PQ1, PQ2

CHQ.245 Did you obtain a diagnosis of a problem from a professional? ECLS-K Diagnoses for 

hearing ability

PQ1, PQ2

CHQ.246/246OS What was the diagnosis? ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ250a/b/c How old was {CHILD} when the first diagnosis of a problem related to {his/her} {ability to

communicate/hearing} was made?

ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ.255a/b What was the month and year the problem with {CHILD}'s {ability to communicate/hearing} was 

diagnosed? 

ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ.256a Since last spring, has {CHILD} worn a hearing aid? ECLS-K:2011 Use of hearing aid PQ1, PQ2

CHQ.256b Has {CHILD} ever worn a hearing aid? ECLS-K:2011 (modified) Use of hearing aid PQ1, PQ2

CHQ.257a/b At what age was the recommendation that {CHILD} wear a hearing aid first made? ECLS-K:2011 Use of hearing aid PQ1, PQ2

Page 20 of 30
App B Spring 4th Parent Intervi

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149

150

151

152

153

154

155

156

157

158

159

160

161

A B C D E F

CHQ.258 How often does {CHILD} use the hearing aid(s) in school? Would you say...

All of the time,

Most of the time,

Sometimes,

Rarely, or

Never?

ECLS-K:2011 Use of hearing aid PQ1, PQ2

CHQ.259 Please indicate whether the following statement describes {CHILD}'s hearing when wearing 

{his/her} hearing aid(s). {CHILD} can usually hear and understand what a person says without 

seeing his or her face if that person whispers to {him/her} from across a quiet room.

ECLS-K:2011 Hearing ability: with 

hearing aid

PQ1, PQ2

CHQ.260 [Please indicate whether the following statement describes {CHILD}'s hearing when wearing 

{his/her} hearing aid(s). ] {CHILD} can usually hear and understand what a person says without 

seeing his or her face if that person talks in a normal voice to {him/her} from across a quiet room.

ECLS-K:2011 Hearing ability: with 

hearing aid

PQ1, PQ2

CHQ.261 [Please indicate whether the following statement describes {CHILD}'s hearing when wearing 

{his/her} hearing aid(s). ] {CHILD} can usually hear and understand what a person says without 

seeing his or her face if that person shouts to {him/her} from across a quiet room.

ECLS-K:2011 Hearing ability: with 

hearing aid

PQ1, PQ2

CHQ.262 [Please indicate whether the following statement describes {CHILD}'s hearing when wearing 

{his/her} hearing aid(s).] {CHILD} can usually hear and understand what a person says without 

seeing his or her face if that person speaks loudly into {his/her} {better} ear.

ECLS-K:2011 Hearing ability: with 

hearing aid

PQ1, PQ2

CHQ.263 {Since last spring has/Has} a doctor or other health care professional {ever} recommended that

{CHILD} wear a hearing aid?

ECLS-K:2011 Use of hearing aid PQ1, PQ2

CHQ.264a/b At what age was the recommendation that {CHILD} wear a hearing aid first made? ECLS-K:2011 Use of hearing aid PQ1, PQ2

CHQ.270 Does {CHILD} have a cochlear implant? ECLS-K Use of cochlear 

implant

PQ1, PQ2

CHQ.271 In what year was it implanted? ECLS-K Use of cochlear 

implant

PQ1, PQ2

CHQ.272a/b How old was {CHILD} when it was implanted? ECLS-K:2011 Use of cochlear 

implant

PQ1, PQ2

CHQ.273 In what years were they implanted? ECLS-K Use of cochlear 

implant

PQ1, PQ2

CHQ.274 [In what years were they implanted?] ECLS-K Use of cochlear 

implant

PQ1, PQ2

CHQ.275a/b {How old was {CHILD} when it was implanted in the left ear?}{How old was {CHILD} when they

were implanted?}

ECLS-K:2011 Use of cochlear 

implant

PQ1, PQ2

CHQ.276a/b {How old was {CHILD} when it was implanted in the right ear?}{How old was {CHILD} when they

were implanted?}

ECLS-K:2011 Use of cochlear 

implant

PQ1, PQ2

Page 21 of 30
App B Spring 4th Parent Intervi

162

163

164

165

A B C D E F

CHQ.277 Please indicate whether the following statement describes {CHILD}'s hearing when wearing 

{his/her} cochlear implant {s}. {CHILD} can usually hear and understand what a person says 

without seeing his or her face if that person whispers to {him/her} from across a quiet room.

ECLS-K:2011 Hearing ability: with 

cochlear implant

PQ1, PQ2

CHQ.278 [Please indicate whether the following statement describes {CHILD}'s hearing when wearing 

{his/her} cochlear implant {s}.]{CHILD} can usually hear and understand what a person says 

without seeing his or her face if that person talks in a normal voice to {him/her} from across a 

quiet room.

ECLS-K:2011 Hearing ability: with 

cochlear implant

PQ1, PQ2

CHQ.279 [Please indicate whether the following statement describes {CHILD}'s hearing when wearing 

{his/her} cochlear implant {s}.] {CHILD} can usually hear and understand what a person says 

without seeing his or her face if that person shouts to {him/her} from across a quiet room.

ECLS-K:2011 Hearing ability: with 

cochlear implant

PQ1, PQ2

CHQ.280 [Please indicate whether the following statement describes {CHILD}'s hearing when wearing 

{his/her} cochlear implant {s}.] {CHILD} can usually hear and understand what a person says 

without seeing his or her face if that person speaks loudly into {his/her} {better} ear.

ECLS-K:2011 Hearing ability: with 

cochlear implant

PQ1, PQ2

Page 22 of 30
App B Spring 4th Parent Intervi

166

167

168

169

170

171

172

173

A B C D E F

CHQ.285 Now I want to ask you about {CHILD}’s vision. Without the use of eyeglasses or contact lenses,

does {CHILD} have difficulty seeing objects in the distance or letters on paper?

ECLS-K Vision ability PQ1, PQ2

CHQ.286 Is {CHILD}’s difficulty with seeing objects in the distance, things up close (like letters on paper), or

both?

ECLS-K:2011 Vision ability PQ1, PQ2

CHQ.290 {Since last spring has/Has} {CHILD}'s vision {ever} been evaluated by an eye care professional? ECLS-K (modified) Evaluated for vision 

ability

PQ1, PQ2

CHQ.300 Did you obtain a diagnosis of a vision-related problem from an eye care professional? ECLS-K (modified) Diagnoses for visionrelated problemsPQ1, PQ2

CHQ.301/301OS What was the diagnosis? ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ.305a/b How old was {CHILD} when the first diagnosis of a problem was made? ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ.310a/b What was the month and year the diagnosis was made? ECLS-K:2011 Diagnoses of 

disabilities and 

health conditions

PQ1, PQ2

CHQ.311 Has {CHILD} been prescribed glasses or contact lenses to improve {his/her} vision? ECLS-K:2011 Use of glasses or 

contact lenses

PQ1, PQ2

Page 23 of 30
App B Spring 4th Parent Intervi

174

175

176

177

178

179

180

181

182

183

A B C D E F

CHQ.312 How often does {CHILD} wear glasses or contact lenses?

All of the time,

Most of the time,

Sometimes,

Rarely, or

Never?

ECLS-K:2011 Use of glasses or 

contact lenses

PQ1, PQ2

CHQ.313 Does {CHILD} have glasses or contact lenses? ECLS-K:2011 Use of glasses or 

contact lenses

PQ1, PQ2

CHQ.314 Do {CHILD}’s glasses or contacts help {him/her} see things up close, see things in the distance, or

both?

ECLS-K:2011 Use of glasses or 

contact lenses

PQ1, PQ2

CHQ.330 Would you say {CHILD}'s health is ...

Excellent,

Very good,

Good,

Fair, or

Poor?

ECLS-K Child's general health PQ1, PQ2

CHQ.340 During this school year, has {CHILD} received therapy services or taken part in a program for 

children with disabilities?

ECLS-K Services for 

disabilities

PQ1, PQ2

CHQ.420 During this school year, did {CHILD} participate in a special education program? ECLS-K (modified) Participation in 

school services for 

disabilities

PQ1, PQ2

CHQ.430 Overall, how satisfied are you with the progress {CHILD} has made in the special services or 

special education program this school year? Are you...

Completely satisfied,

Very satisfied,

Fairly satisfied,

Somewhat dissatisfied, or

Very dissatisfied?

ECLS-K:2011 Rating school 

services for 

disabilities

PQ1, PQ2

Parent's 

Psychological 

Well-Being and 

Health

PPQ.100 I'm going to read some statements that may relate to how you have felt about yourself and your 

life during the past week. For each statement I read, please indicate how often in the past week 

you felt or behaved this way. There are no right or wrong answers.

How often during the past week have you felt that you were bothered by things that don't usually 

bother you? Would you say never, some of the time, a moderate amount of the time, or most of 

the time?

ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.110 How often during the past week have you felt that you did not feel like eating, that your appetite 

was poor?

ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.120 How often during the past week have you felt that you could not shake off the blues even with 

help from your family or friends?

ECLS-K Depression and 

subjective well-being

PQ1, PQ3

Page 24 of 30
App B Spring 4th Parent Intervi

184

185

186

187

188

189

190

191

192

193

194

A B C D E F

PPQ.130 How often during the past week have you felt that you had trouble keeping your mind on what 

you were doing?

ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.140 How often during the past week have you felt depressed? ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.150 How often during the past week have you felt that everything you did was an effort? ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.160 How often during the past week have you felt fearful? ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.170 How often during the past week have you felt your sleep was restless? ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.180 How often during the past week have you felt that you talked less than usual? ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.190 How often during the past week have you felt lonely? ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.200 How often during the past week have you felt sad? ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.210 How often during the past week have you felt that you could not get going? ECLS-K Depression and 

subjective well-being

PQ1, PQ3

PPQ.220 Now, I would like to ask you about your health. In general, would you say that your health is...

Excellent,

Very good,

Good,

Fair, or

Poor?

ECLS-K Parent health PQ1, PQ3, PQ5

PPQ.225 During the past 12 months, would you say that you experienced a lot of stress, a moderate 

amount of stress, relatively little stress, or almost no stress at all?

CAM Parent health PQ1, PQ3, PQ5

Page 25 of 30
App B Spring 4th Parent Intervi

195

196

197

198

199

200

201

202

203

204

205

206

207

A B C D E F

Food Security

FDQ.130a/b/c

These next questions are about whether your family is able to afford the food that you need. I am 

going to read you several statements that people have made about their food situation. For these 

statements, please tell me whether the statement was often true, sometimes true, or never true 

for {you/your household} in the last 12 months, that is, since last {CURRENT MONTH}, 2014.

a. {I/We} worried whether {my/our} food would run out before {I/we} got money to buy more.

b. The food that {I/we} bought just didn't last, and {I/we} didn't have money to get more. 

c. {I/We} couldn't afford to eat balanced meals.

ECLS-K Family food security PQ1, PQ3

FDQ.140 In the last 12 months, did {you/you or other adults in your household} ever cut the size of your 

meals or skip meals because there wasn't enough money for food?

ECLS-K Family food security PQ1, PQ3

FDQ.150 How often did this happen? Would you say...

Almost every month

Some months, but not every month, or

In only 1 or 2 months?

ECLS-K Family food security PQ1, PQ3

FDQ.160 In the last 12 months, did you ever eat less than you felt you should because there wasn't enough 

money for food?

ECLS-K Adult food security PQ1, PQ3

FDQ.170 In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money 

for food?

ECLS-K Adult food security PQ1, PQ3

FDQ.180 In the last 12 months, did you lose weight because there wasn't enough money for food? ECLS-K Adult food security PQ1, PQ3

FDQ.190 In the last 12 months, did {you/you or other adults in your household} ever not eat for a whole 

day because there wasn't enough money for food?

ECLS-K Adult food security PQ1, PQ3

FDQ.191 How often did this happen? Would you say...

Almost every month,

Some months, but not every month, or

In only 1 or 2 months?

ECLS-K Adult food security PQ1, PQ3

Parent's 

Education

PEQ.020 {Now I have a few questions about education.} What is the highest grade or year of school that 

{you/{NAME}} {have/has} completed?

ECLS-K:2011 (modified) Parent education PQ1, PQ3

PEQ.021 {Do/Does} {you/{NAME}} have a high school diploma, or its equivalent, such as a GED, or neither? ECLS-K Parent education PQ1, PQ3

PEQ.030 {Are you/Is {NAME}} currently attending or enrolled in any courses from a school, college, or 

university?

ECLS-K:2011 Parent education PQ1, PQ3

PEQ.040 {Are you/Is {NAME}} currently taking courses full-time or part time? ECLS-K:2011 Parent education PQ1, PQ3

PEQ.050 {Are you/Is {NAME}} currently participating in a job training or on the job training program? 

Please do not report participation in any vocational or technical programs taken at a college or 

university that you just told me about.

ECLS-K:2011 Parent education PQ1, PQ3

Page 26 of 30
App B Spring 4th Parent Intervi

208

209

210

211

212

213

214

215

216

217

218

219

220

221

A B C D E F

PEQ.060 About how many hours a week {do/does} {you/{NAME}} spend in that program? Please include 

hours spent on homework for the training program.

ECLS-K:2011 Parent education PQ1, PQ3

PEQ.062 What type of school or job training {are you/Is {NAME}} currently in? ECLS-K:2011 Parent education PQ1, PQ3

Parent's 

Employment 

Section 1 (NAEP 

sample only)

EMQ.020

During the past week, did {you/{NAME}} work at a job for pay?

ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.030 {Were you/Was {NAME}} on leave or vacation from a job? ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.040 How many jobs {do you/does {NAME}} have now? ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.050 About how many total hours per week {do you/does {NAME}} usually work for pay {counting 

{all/both} {# of jobs from EMQ.040 IF MORE THAN TWO} jobs}?

ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.060 {Have you/Has {NAME}} been actively looking for work in the past 4 weeks? By actively looking 

for work, we mean activities such as checking with a public employment agency, a private 

employment agency, or an employer directly; checking about jobs with friends or relatives; 

placing or answering ads; sending a resume; contacting a school or university employment 

center; or checking a union or professional register.

ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.070 What {have you/has {NAME}} been doing in the past 4 weeks to find work? ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.080 What {were you/was {NAME}} doing most of last week? Would you say...

Keeping house, or caring for children or other family members,

Going to school,

Retired,

Unable to work, or

Something else? What was that? (SPECIFY)

ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.100 Could {you/{NAME}} have taken a job last week if one had been offered? ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.120 For whom {do/does/did} {you/{NAME}} work {when {you/{he/she}}last worked}? ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.130 What kind of business or industry {is/was} this? ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.140 What kind of work {are/is/were/was} {you {NAME}} doing? ECLS-K:2011 Parent employment PQ1, PQ3

EMQ.150 What {are/is/were/was} {your/{NAME}'s} most important activities or duties on this job? What 

{do/does/did} {you/{NAME}} actually do at this job?

ECLS-K:2011 Parent employment PQ1, PQ3

Page 27 of 30
App B Spring 4th Parent Intervi

222

223

224

225

226

227

228

A B C D E F

Parent's 

Employment

EMQ.200 Which best describes {your/NAME'S} current employment situation? {Are you/Is {NAME}}...

working part-time,

working full-time,

a stay-at-home parent or guardian, or

not working?

Westat Parent employment PQ1, PQ3

EMQ.210 {Since last spring/Since {CHILD} was born}, {have you/has {NAME}} served on active duty in the

U.S. Armed Forces, military Reserves, or National Guard? Active duty does not include training

for the Reserves or National Guard, but DOES include activation, for example, for the war in

Afghanistan.

United States Census Bureau 

(modified)

Active duty military 

service: since child 

was born

PQ1, PQ3

EMQ.215 {Are you/Is {NAME}} currently on active duty in the U.S. Armed Forces, military Reserves, or

National Guard?

United States Census Bureau 

(modified)

Active duty military 

service: current

PQ1, PQ3

Welfare and 

Other Public 

Transfers

WPQ.100 In the past 12 months, have you or anyone in your household received Temporary Assistance for

Needy Families, sometimes called {TANF or} {STATE TANF PROGRAM NAME}?

ECLS-K:2011 Public assistance PQ1, PQ3

WPQ.110 In the past 12 months, have you or anyone in your household received food stamps, also called 

SNAP (the Supplemental Nutrition Assistance Program), or food benefits on EBT (Electronic 

Benefit Transfer)?

ECLS-K:2011 Public assistance PQ1, PQ3

WPQ.170 Does {CHILD} receive complete school lunches for free or reduced price at school? ECLS-K:2011 Free/reduced lunch PQ1, PQ3

Parent Income 

and Assets

PAQ.100 In studies like this, households are sometimes grouped according to income. What was the total 

income of all persons in your household over the past year, including salaries or other earnings, 

interest, retirement, and so on for all household members? Was it...

$25,000 or less, or

More than $25,000?

ECLS-K Annual family income PQ1, PQ3

Page 28 of 30
App B Spring 4th Parent Intervi

229

230

231

232

233

234

A B C D E F

PAQ.110 Was it...

$5,000 or less

$5,001 to $10,000

$10,001 to $15,000

$15,001 to $20,000

$20,001 to $25,000

$25,001 to $30,000

$30,001 to $35,000

$35,001 to $40,000

$40,001 to $45,000

$45,001 to $50,000

$50,001 to $55,000

$55,001 to $60,000

$60,001 to $65,000

$65,001 to $70,000

$70,001 to $75,000

$75,001 to $100,000

$100,001 to $200,000

$200,001 or more

ECLS-K Annual family income PQ1, PQ3

PAQ.120 What was your total household income last year, to the nearest thousand? ECLS-K Annual family income PQ1, PQ3

PAQ.140/140OS What is your current housing situation? Do you...

own your own house or condominium, 

rent your house or apartment, 

exchange services for housing, 

not pay for housing, 

live in temporary housing or a shelter, 

live with a relative or in a dwelling owned by a relative (MAY OR MAY NOT CONTRIBUTE TO

EXPENSES OR CONTRIBUTION UNKNOWN), or 

have another type of arrangement (SPECIFY)?

ECLS-K Housing PQ1, PQ3

Mobility and 

Tracking 

Updates

CMQ.010 Have you moved since {DATE OF LAST INTERVIEW}? ECLS-K Child Mobility NA

CMQ.020/020OS Why did you move? ECLS-K Child Mobility NA

CMQ.060 Just to make sure I can reach you for the next interview, which will take place next school year, 

I'd like to ask a few questions about how to find you.

Is there a second phone number, such as a work number, a friend or relative's number, or a 

beeper or cell phone number, where you can sometimes be reached?

ECLS-K Closing NA

Page 29 of 30
App B Spring 4th Parent Intervi

235

236

237

238

239

240

241

242

243

244

245

246

247

248

249

250

251

252

A B C D E F

CMQ.100 Just to make sure I can reach you for the next interview, which will take place next school year, 

I'd like to ask a few questions about how to find you. I have recorded {PHONE NUMBER} as a 

second phone number where you can sometimes be reached. Is this the right number?

ECLS-K Closing NA

CMQ.140 What is that telephone number? ECLS-K Closing NA

CMQ.150/155 Where is that telephone located? ECLS-K Closing NA

CMQ.200 I have recorded that {NAME OF RELATIVE/FRIEND}

at {PHONE NUMBER}

on

{STREET ADDRESS, LINE 1}

{STREET ADDRESS, LINE 2}

{CITY}

{STATE}

{ZIP CODE}

will always know where you are if you move. Is this still true?

ECLS-K Closing NA

CMQ.205 Is there a relative or friend, who does not live in this household, who will always know where you 

are if you move?

ECLS-K Closing NA

CMQ.210/220/23

0/240/250/255/2

55OS/260/270

What is the name, address, and telephone number of that person? ECLS-K Closing NA

CMQ.280 What is the person's relationship to you? ECLS-K Closing NA

CMQ.382 I have also recorded that your e-mail address is {EMAIL ADDRESS}. Is that correct? ECLS-K Closing NA

CMQ.383 Is there an e-mail address where we could reach you? ECLS-K Closing NA

CMQ.384 What is your e-mail address? ECLS-K Closing NA

CMQ.680 WAS THIS INTERVIEW CONDUCTED BY TELEPHONE OR IN-PERSON? ECLS-K Closing NA

CMQ.690/690OS WAS THIS INTERVIEW CONDUCTED IN ENGLISH, SPANISH, A CHINESE LANGUAGE, VIETNAMESE, 

OR ANOTHER LANGUAGE?

ECLS-K Closing NA

CMQ.695 WHERE WAS THIS INTERVIEW CONDUCTED? ECLS-K Closing NA

CMQ.700 Thank you very much for your cooperation and for taking the time to participate in the Early 

Childhood Longitudinal Study.

ECLS-K Closing NA

CMQ.701 We would like to call the parent or guardian for {CHILD} at the household where {he/she} lives. 

Could you please give me the name and telephone number for the home that I should call?

ECLS-K Closing NA

CMQ.702 We would like to call back when {this person/{CHILD}’s parent or guardian is available. Please tell 

me when we should call back. 

ECLS-K Closing NA

CMQ.703 Thank you. ECLS-K Closing NA

CMQ.720 PRESS 1 AND ENTER TO SAVE AND EXIT THIS CASE. ECLS-K Closing NA

Page 30 of 30
Section Item # Item Stem Source

A1 a-d Which of the following subjects do you teach 

during this school year?

ECLS-K:2011 

Grade 3

a. Reading/language arts

b. Mathematics

c. Science

d. Social studies

A2 a-j How often does the typical child in your class(es) 

usually work on lessons or projects in the following 

general subject areas, whether as a whole class, in 

small groups, or in individualized arrangements? 

a. Reading and language arts

b. Mathematics

c. Social studies

d. Science

e. Music

f. Art

g. Physical education

h. Dance/creative movement

i. Theatre/creative dramatics

j. Foreign language (excluding English for ELL 

students)

ECLS-K

A3 a -j On days when children have work in these areas, 

how much time does the typical child in your 

class(es) usually work on lessons or projects in the 

following general subject areas?

a. Reading and language arts

b. Mathematics 

c. Social studies

d. Science

e. Music

f. Art

g. Physical education

h. Dance/creative dramatics

i. Theatre/creative dramatics

j. Foreign language (excluding English for ELL 

students)

ECLS-K

Spring Fourth-Grade General Classroom Teacher Questionnaire, Appendix H

Student, School, 

and Staff Activities
A4 How many days a week do children have recess? 

Zero; One; Two; Three; Four; Five; Other/Varies by 

week

ECLS-K

A5 On days when children have recess, between the 

school day starting time and the dismissal time, 

how many times a day do children have recess?

One; Two; Three; Four; Five; Other/Varies by day

ECLS-K

A6 a-d What percentage of children in your class(es) have 

parents who participate in the following activities?

a. Attend teacher-parent conferences

b. Volunteer regularly to help in your

classroom or another part of the school

c. Attend open houses or parties

d. Attend art/music events or demonstrations

ECLS-K

A7 a-i How important is each of the following in 

evaluating the children in your class(es) for 

reporting to parents?

a. Individual child's achievement relative

to the rest of the class

b. Individual child's achievement relative

to local, state, or professional standards

c. Individual improvement or progress

over past performance

d. Effort

e. Class participation

f. Daily attendance

g. Classroom behavior or conduct

h. Cooperativeness with other children

i. Ability to follow directions

ECLS-K

Please indicate the extent to which you agree or 

disagree with each of the following statements 

about your school.

a. The level of child misbehavior ) for example, 

noise, horseplay, or fighting in the halls or 

cafeteria) in this school interferers with my 

teaching.

b. Many of the children I teach are not capable of 

learning the material I am supposed to teach them.

c. Parents are supportive of school staff.

d. There is a great deal of cooperative effort 

among the staff members.

Views on School 

Climate and School 

Environment

B1 a-h ECLS-K
e. There is a consensus among administrators and 

teachers on goals and expectations.

f. The academic standards at this school are too 

low.

g. The school administrator sets priorities, makes 

plans, and sees that they are carried out.

h. The school administration's behavior toward the 

staff is supportive and encouraging.

B2 a-e To what extent do you agree or disagree with the 

following statements? 

a. The attitudes and habits students bring

to my class﴾es﴿ greatly reduce their

chances for academic success.

b. My success or failure in teaching is due

primarily to factors beyond my control

rather than to my own effort or ability.

c. The amount a student can learn is

primarily related to family background.

d. I really enjoy my present teaching job.

e. If I could start over, I would choose

teaching again as my career.

ECLS-K

Teacher 

Background

C1 What is your gender? ECLS-K

C2 In what year were you born? ECLS-K

C3 Are you Hispanic or Latino? ECLS-K

C4 Which best describes your race? MARK ONE OR 

MORE RESPONSES TO INDICATE WHAT YOU 

CONSIDER YOURSELF TO BE.

American Indian or Alaska Native; Asian; Black or 

African American; Native Hawaiian or Other Pacific 

Islander; White

ECLS-K
C5 a-j Counting this school year, how many years have 

you taught each of the following grades and 

programs, including years in which you taught part 

time?

a. Preschool or kindergarten

b. First grade

c. Second grade

d. Third grade

e. Fourth grade

f. Fifth grade

g. Sixth grade or higher

h. English as a Second Language (ESL), bilingual 

education, and/or dual language program

i. Special education program

j. Program for gifted children

ECLS-K

C6 Counting this school year, how many total years 

have you been a school teacher, including years in 

which you taught part-time?

ECLS-K

C7 Is this school year the first year you have taught in 

this school?

New

C8 What is the highest level of education you have 

completed?

Did not complete high school; High school diploma 

or equivalent/GED; Some college or technical or 

vocational school; Associate's degree; Bachelor's 

degree; Master's degree; An advanced professional 

degree beyond a master's degree (for example, 

Ph.D, MD)

ECLS-K
C9 a-n If you have an associate's or bachelor's degree, 

indicate your undergraduate major field of study.

a. Early childhood education

b. Elementary education

c. English

d. Reading and/or language arts

e. Curriculum and instruction

f. Mathematics education

g. Mathematics

h. Science education

i. Life science

j. Physical science

k. Earth science

l. Special education

m. Other education-related major (for example, 

secondary education, educational psychology, 

administration, music education, etc.)

n. Non-education major (for example, history, etc.)

ECLS-K

C10 a-n If you have a graduate degree, indicate the major 

field of study of your highest level graduate degree.

a. Early childhood education

b. Elementary education

c. English

d. Reading and/or language arts

e. Curriculum and instruction

f. Mathematics education

g. Mathematics

h. Science education

i. Life science

j. Physical science

k. Earth science

l. Special education

m. Other education-related major (for example, 

secondary education, educational psychology, 

administration, music education, etc.)

n. Non-education major (for example, history, etc.)

ECLS-K
C11 a-d Have you ever taken a college course that 

addressed issues related to the following?

a. Using published research evidence to identify 

and select effective interventions and supports for 

students

b. Using formal assessment data to inform the 

choice of READING interventions and supports for 

students

c. Using formal assessment data to inform the 

choice of MATH interventions and supports for 

students

d. Using data to inform the choice of behavioral 

interventions and supports for students

C12 Which of the following describes the teaching 

certificate you currently hold in THIS state?

Regular or standard 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 hold any of the above 

certifications in THIS state.

ECLS-K

C13 Date questionnaire completed
Construct

Research 

Question 6/10/14 Comments

Subjects taught TQ3

Use of class time, by subject area TQ1 added (es) in item stem.

Use of class time, by subject area TQ1 added (es) in item stem.
Class activities (outside of class)/ 

recess

TQ1

Class activities (outside of class)/ 

recess

TQ1

Parent involvement in school TQ2 added (es) in item stem.

Methods of assessing children's 

progress 

TQ1 added (es) in item stem.

School climate TQ4
Teacher’s sense of efficacy; Job 

satisfaction

TQ4

Teacher demographic information TQ4

Teacher demographic information TQ4

Teacher demographic information TQ4

Teacher demographic information TQ4
Teaching experience, by grade 

and program

TQ4

Teaching experience, total years TQ4

First year teaching in this school TQ4

Teacher's education TQ4
Teacher's education: major field 

of study

TQ4

Teacher's education: major field 

of study

TQ4
Teacher's education: coursework ; 

Response to Intervention-related 

practices

TQ4

Type of teaching certification held TQ4

N/A N/A
Section Item # Item Stem Source

Social Skills A1 a-z Items focusing on general social skills in the 

classroom. Items not included due to copyright 

restrictions (26 items total)

 SSRS Elementary 

Scale A; ECLS-K

Please indicate how often each of these items 

applies to the child identified on the cover of this 

questionnaire.

a. Likes to come to school

b. Dislikes school

c. Has fun at school

d. Likes being in school

e. Seems unhappy in school

f. Enjoys most classroom activities

g. Groans or complains about suggested activities

Classroom 

Behaviors

B1 a-m Item about classroom behaviors. Items not 

included due to copyright restrictions (13 items 

total)

TMCQ

For the items below, please think about the friends 

with whom the child identified on the cover of this 

questionnaire has associated the most during the 

past month or two. Please indicate how true you 

think each of these items is for this group of 

children. If you cannot answer these items because 

the child has not usually associated with a group of 

other children in the past month or two, then mark 

"Not applicable."

a. This is a good group of kids

b. I worry when this child is with this group

c. Some of these kids are a bad influence

d. These kids must be closely supervised by an adult

e. These kids get into trouble

f. These kids are excellent students

g. These kids are hard workers

h. This child has a fun time with this group

i. Most of these kids are kind to other children

Peer Relationships C1 a-i Adapted from 

Vandell, 2001.

Spring Fourth-Grade Reading and Language Arts Teacher Questionnaire, Appendix H

Part 1: Please answer the questions in Part 1 about the child identified on the cover of this questionnaire.

A2 a-g Adapted from 

Ladd & Price, 

1987; Ladd, 1990
C2 a-I Items asking how often certain statements related 

to the child's relationships with peers apply to the 

child. Items not included due to copyright 

restrictions (9 items total)

Adapted from 

the Child 

Behavior Scale. 

Gary W. Ladd, 

2010

During this school year, how often have other 

students...

a. Teased, made fun of, or called this student 

names?

b. Told lies or untrue stories about this student?

c. Pushed, shoved, slapped, hit, or kicked this 

student?

d. Intentionally excluded or left this student out 

from playing with them?

C4 a-d During this school year, how often has this student...

a. Teased, made fun of, or called

other students names?

b. Told lies or untrue stories about

other students?

c. Pushed, shoved, slapped, hit, or

kicked other students?

d. Intentionally excluded or left other

students out from playing with him

or her?

Source: Adapted 

from Espelage 

and Holt, 2001

Thinking about the child identified on the cover of 

this questionnaire compared to a typical child in 

his/her grade, please evaluate this child in the 

following areas.

a. Understands others' feelings

b. Accurately interprets what a peer is trying to do 

c. Generates good quality solutions to 

interpersonal problems

d. Is aware of the effects of his/her behavior on 

others

C3 a-d Source: Adapted 

from Espelage 

and Holt, 2011

C5 a-d Source: Pierce, 

Hamm, and 

Vandell, 1999.
Student 

Information

D1 a-d Are you this child's primary teacher in the following 

subject areas?

a. Reading/language arts

b. Mathematics

c. Science

d. Social studies

ECLS-K

D2 How long has this child been in your 

reading/language arts class this school year until 

now? 

Entire school year until now; More than one 

semester but less than the entire school year until 

now; More than one quarter but less than one 

semester; Less than one quarter of the school year

ECLS-K

D3 Please indicate the total number of times this child 

has been absent from your reading/language arts 

class during the current school year.

No absences; 1 to 4 absences; 5 to 7 absences; 

8 to 10 absences; 11 to 19 absences; 20 or more 

absences

ECLS-K

D4 a-c Does this child receive (or has he/she received 

during this school year) instruction in any of the 

following types of programs in your school?

a. Individual tutoring or remedial program in 

reading/language arts

b. Gifted and talented program in 

reading/language arts

c. Gifted and talented program with no specific 

content focus 

ECLS-K

D5 Is English this child's native language? ECLS-K

D6 Does this child participate in an instructional 

program designed to teach English language skills 

to children with limited English proficiency? 

ECLS-K
D7 Would you say the instruction this child receives is 

primarily ...

Programs that focus on developing students' 

literacy in two languages. For example:

Two-way immersion program or two-way bilingual 

program;

Developmental bilingual program, late exit 

transitional program, or maintenance bilingual 

education program;

Transitional program, early exit bilingual program, 

or early exit transitional program;

Heritage language program or indigenous language 

program

Programs that focus on developing students' 

literacy solely in English. For example:

Sheltered English instruction or content-based 

English as a Second Language (ESL) program;

Structured English Immersion (SEI);

Pull-out English as a Second Language (ESL) or 

English Language Development (ELD);

Push-in ESL program

Other program(s) (PLEASE SPECIFY) ; 

No specialized language program is provided to 

this child.

Adapted from 

the "Types of 

language 

instruction 

educational 

programs," 

provided by the 

National 

Clearinghouse for 

English Language 

Acquisition.

D8 a-c How often does this child usually receive 

specialized language instruction of the following 

program types?

a. Program that focuses on developing students' 

literacy in two languages

b. Program that focuses on developing students' 

literacy solely in English

c. Other program

ECLS-K

D9 a-c On the days when this child receives specialized 

language instruction, for how much time does 

he/she receive instruction of the following program 

types?

a. Program that focuses on developing students'

literacy in two languages

b. Program that focuses on developing students'

literacy solely in English

c. Other program

ECLS-K
D10 During this school year, how often is this child's 

reading instruction provided in his/her native 

language?

None of the time; Less than half of the time;

Half of the time; More than half of the time;

Almost all the time

ECLS-K

D11 Does this child have an IEP on record with the 

school? 

ECLS-K

D12 a-b Does this child receive instruction in any of the 

following types of programs in your school?

a. Speech-language therapy for children with 

speech or language disorders/impairments

b. Special education services, not including speech 

therapy, whether provided in the classroom or in a 

pull-out setting

ECLS-K

D13 a-d Overall, how would you rate this child’s academic 

skills in each of the following areas, based on 

curriculum standards for his/her current grade 

level?

a. Reading

b. Writing

c. Oral language

d. Social studies 

ECLS-K

D14 How often does this child work to the best of 

her/his ability in READING AND LANGUAGE ARTS?

Never; Seldom; Usually; Always

ECLS-K

D15 How many instructional groups based on 

achievement or ability levels in READING do you 

currently have in this child's class?

I do not use instructional groups for reading; Two;

Three; Four; Five or more 

ECLS-K

D16 In which reading instructional group is this child 

currently placed? USE "1" FOR THE HIGHEST 

INSTRUCTIONAL GROUP. 

ECLS-K

D17 How involved at the school would you say this 

child’s parents/guardians are?

Not involved at all; Somewhat involved; Very 

involved; Don't know

ECLS-K

Part 2: To be completed only if there is a red dot next to the child's name on the cover of this questionnaire. 
From the first day of school until today, please 

indicate on how many days you have covered each 

of the following READING AND LANGUAGE ARTS 

skills and concepts in this child's class. Please 

include the time during which you provide direct 

instruction as well as the time you spend 

supervising students as they work.

Literature

a. Understanding key ideas and details, for

example, identifying the main idea or theme;

summarizing; describing characters and

settings; etc.

b. Understanding craft and structure, for

example, explaining major differences between

poems, plays, and prose; comparing the point

of view from which different stories are

narrated; etc.

c. Integrating knowledge and ideas, for example,

making connections between text and a visual

or oral presentation of the text; comparing

treatment of similar themes in stories and

myths; etc.

Informational Text

d. Integrating knowledge and ideas, for example,

making connections between text and a visual

or oral presentation of the text; comparing

treatment of similar themes in stories and

myths; etc. e. Understanding craft and structure, for example, 

describing the chronology of events in a text; 

recognizing cause and effect; comparing different 

accounts of the same event or topic; etc.

f. Integrating knowledge and ideas, for example, 

interpreting how charts, graphs, or timelines relate 

to the text; integrating information from two texts 

onb the same topic; etc.

Writing and Language

g. Writing narratives, opinion pieces, and 

informational text with facts and details

h. Developing and strengthening writing by 

planning, drafting, revising, and editing

i. Building vocabulary, for example, studying 

words and their meanings in text; learning about 

roots, prefixes, and suffixes; using context clues to 

derive meaning; etc.

Reading and 

Language Arts 

Instruction

E1 a-i ECLS-K, updated 

to reflect 

"Common Core 

State Standards," 

corestandards.org
E2 a-k How often do the children in this class engage in 

the following reading and language arts activities?

a. Read silently

b. Read books they have chosen themselves

c. Talk with others about what they have read

d. Do a group activity or project about what they 

have read

e. Discuss different interpretations of what they 

have read

f. Look up vocabulary words and write

definitions

g. Demonstrate understanding of words by relating 

them to their opposites ﴾antonyms﴿ and to words

with similar meanings ﴾synonyms﴿

h. When given specific questions, write responses

that are at least 3 to 4 sentences long

i. Gather evidence from literary or informational 

texts ﴾in books and/or digital sources﴿ to inform

their writing

j. Spend extended time writing and revising text 

that they have written

k. Edit their classmates' writing

ECLS-K, updated 

to reflect 

"Common Core 

State Standards," 

corestandards.org

Classroom and 

Student 

Characteristics

F1 a-c As of today’s date, how many children...

a. Are currently enrolled in this class?

b. Are boys?

c. Are girls?

ECLS-K

F2 a-e What grade levels are included in this class?

a. 2nd grade or lower

b. 3rd grade

c. 4th grade

d. 5th grade

e. 6th grade or higher

ECLS-K

F3 How many of the children in this class are repeating 

their grade this year?

ECLS-K

F4 a-b How many children in this class...

a. Are classified as Gifted and Talented?

b. Are participating in a Gifted and Talented 

program?

ECLS-K

F5 How many children in this class are absent on an 

average day?

ECLS-K
F6 a-b How many children in this class are below grade 

level, about on grade level, or above grade level in 

their English reading skills and in social studies?

a. English reading skills?

b. Social studies?

ECLS-K

F7 At this point in the school year, how would you rate 

the behavior of the children in this class?

Group misbehaves very frequently and is almost 

always difficult to handle.

Group misbehaves frequently and is often difficult 

to handle.

Group misbehaves occasionally.

Group behaves well.

Group behaves exceptionally well.

ECLS-K

F8 a-d Approximately what percentage of the students in 

this class demonstrate the following problems?

a. Have difficulty paying attention in class

b. Lack self-control ﴾disruptive behavior﴿

c. Are rejected by peers

d. Do not accept authority

New. From Abry, 

Swanson, & 

Fabes (2012)

F9 How many children in this class have a diagnosed 

disability? 

ECLS-K

F10 Do you have any children who are English language 

learners in this class? (English language learners are 

children whose native language is one other than 

English and whose skills in listening, speaking, 

reading, or writing English are such that they have 

difficulty understanding school instruction in 

English.) 

ECLS-K

F11 How many English language learners (ELLs) do you 

have in this class?

ECLS-K

Classroom 

Instruction and 

Evaluation

G1 a-e In a typical day, how much time do children in this 

reading and language arts class spend in the 

following activities?

a. Working independently

b. Working on individual tasks under teacher 

direction

c. Working with peers under teacher direction

d. Working in small groups with teacher

e. Teacher lecture with large group and/or large 

group discussion led by teacher

ECLS-K:2011 

Grade 1
G2 a-b Do any of the following staff members provide 

direct instruction to students in this reading and 

language arts class who are struggling or at risk of 

failure in reading? INCLUDE STAFF OTHER THAN 

YOURSELF WHO PROVIDE DIRECT INSTRUCTION 

EITHER IN THIS CLASS OR IN A PULL-OUT SETTING. 

EXCLUDE PARAPROFESSIONALS/AIDES.

a. A READING specialist/interventionist who has 

specialized training in reading instruction

b. A special education teacher

Adapted from 

Reading First 

Impact Study--

Teacher Survey

G3 a-h In this class, how frequently do you or your 

students use computers or the following electronic 

devices for instructional purposes in reading and 

language arts? Please include any desktop, laptop, 

or other computer-type devices.

a. Computer ﴾desktop, laptop or

other computer-type device

such as a tablet﴿

b. LCD or DLP projector

c. Interactive whiteboard ﴾for example, SMART 

Board, Activboard﴿

d. Digital camera ﴾still or video﴿

e. CD player or MP3 player/iPod

f. DVD player or VCR

g. TV

h. Other electronic devices

(PLEASE SPECIFY)

ECLS-K

G4 In an average week, how many days a week is 

reading and language arts homework assigned in 

this class? Please count homework assigned over 

the weekend as one day.

0 days; 1 day; 2 days; 3 days; 4 days; 5 days

ECLS-K

G5 On days when homework is assigned, how much 

time do you expect children in this class to spend 

on homework in reading and language arts? 

1 to 10 minutes; 11 to 20 minutes; 21 to 30 

minutes; More than 30 minutes

ECLS-K
G6 a-e In this class, how often do you use a formal 

assessment in READING for the following purposes?

a. To evaluate how well each student is responding 

to the core curriculum provided in

the general education classroom

b. To monitor each student's progress on specific 

skills over the school year

c. To identify the deficits in specific skills of 

struggling students

d. To monitor the progress of students who fall 

below benchmark levels

e. To determine whether students need placement 

in a more or less intensive level of

instruction

ECLS-K:2011 

Grade 1

G7 a-c For each of the following statements about 

READING, indicate how strongly you agree or 

disagree.

MARK ONE RESPONSE ON EACH ROW.

a. This school has a set of clear, predetermined, 

grade-level benchmarks ﴾that is, cut scores, 

goals/targets, or percentiles﴿ that are used to

determine which students are struggling or at risk 

of failure in reading in fourth grade.

b. This school has clear, predetermined criteria for

determining the level of intervention fourth-grade

students will receive in reading.

c. This school has clear, predetermined criteria for

determining when fourth grade students no longer

need a reading intervention.

Adapted from 

WA (RTI) and HB 

2136: Spring 2010

Staff Activities H1 Did you participate in any professional 

development within the the last 12 months?

ECLS-K:2011 

Grade 1
H2 a-c How often did you participate in professional 

development activities covering the following 

topics in the last 12 months?

a. How to use assessment data to identify students 

who are struggling or at risk of failure in READING 

b. How to use and apply assessment data to guide 

READING instruction

c. How to implement the READING curriculum

Adapted from 

Reading First 

Impact Study--

Teacher Survey

H3 a-d Have you received support from any of the 

following staff members during the current 

academic year?

a. A school or district staff member whose role is 

to provide ongoing training and support to 

classroom teachers in the delivery of effective 

READING instruction

b. A school or district staff member who provides

ongoing training and support to classroom teachers 

in the delivery of effective behavioral supports

c. A school or district staff member who supports

teachers in collecting, organizing, and managing

assessment data 

d. A school or district staff member who supports

teachers in the interpretation and use of 

assessment data to guide instruction

ECLS-K:11 Grade 1

H4 Date Questionnaire Completed:
Construct

Research 

Question

Social skills and approaches to 

learning

TQ5

Social skills and approaches to 

learning

TQ5

Peer relationships TQ5

, Appendix H

questionnaire.

School liking and avoidance TQ5
Peer acceptance/exclusion TQ5

Victimization of other students by 

this student

TQ5

Target of victimization by other 

students

TQ5

Peer relationships TQ5
Grade/class configuration TQ1

Family mobility TQ3

Attendance TQ3; TQ5

Receipt of remedial or gifted 

services

TQ3; TQ7

Native language other than English TQ2; TQ3

Receipt of instruction for English 

language learners

TQ1; TQ3
Receipt of instruction for English 

language learners

TQ1; TQ3

Receipt of instruction for English 

language learners

TQ1; TQ3

Receipt of instruction for English 

language learners

TQ1; TQ3
Receipt of instruction for English 

language learners

TQ1; TQ3

IEP status TQ3; SEQ1

Receipt of special education 

services

TQ1; TQ3; 

SEQ1

Comparison to peers: academic 

skills for current grade level in 

reading, language arts, and social 

studies

TQ5

Working to the best of one's 

ability

TQ5

Use of achievement grouping: 

Reading

TQ1; TQ3

Placement in achievement 

grouping: Reading

TQ5

Parent involvement in school 

activities

TQ2

his questionnaire. 
Time spent on specific activities 

and skills in reading/language arts

TQ7
Time spent on specific activities 

and skills in reading/language arts

TQ7

Classroom characteristics: 

enrollment, gender distribution

TQ1; TQ2

Classroom characteristics: grade 

levels within class

TQ2

Classroom characteristics: 

number of repeaters

TQ2; TQ3

Classroom characteristics: 

number of gifted and talented

TQ3

Student absenteeism TQ2
Students above or below grade 

level in reading/social studies

TQ3

Overall behavior of the class TQ2; TQ5

Classroom climate (student 

difficulties)

TQ2; TQ5

Number of students with 

disabilities

TQ3

Number of English language 

learners

TQ3

Number of English language 

learners

TQ3

Proportion of time students 

spend working independently, 

small group, large group

TQ1
Response to Intervention-related 

policies and practices

TQ6

Availability, use, and adequacy of 

resources

TQ1

Use of homework TQ1

Use of homework TQ1
Response to Intervention-related 

policies and practices

TQ6

Response to Intervention-related 

policies and practices

TQ6

Professional development 

activities

TQ4
Professional development 

activities; Response to 

Intervention-related policies and 

practices

TQ6

Response to Intervention-related 

policies and practices

TQ6

N/A
Section Item # Item Stem Source

Student 

Information

A1 a-d Are you this child's primary teacher in the following 

subject areas?

a. Reading/language arts

b. Mathematics

c. Science

d. Social studies 

ECLS-K

A2 How long has this child been in your math class this 

school year until now?

Entire school year until now; More than one 

semester but less than the entire school year until 

now; More than one quarter but less than one 

semester; Less than one quarter of the school year 

ECLS-K

A3 Please indicate the total number of times this child 

has been absent from your math class during the 

current school year.

No absences; 1 to 4 absences; 5 to 7 absences;

8 to 10 absences; 11 to 19 absences; 20 or more 

absences 

ECLS-K

A4 a-b Does this child receive (or has he/she received 

during this school year) instruction in any of the 

following types of programs in your school?

a. Individual tutoring or remedial program in 

mathematics

b. Gifted and talented program in mathematics 

ECLS-K

A5 Is English this child's native language? ECLS-K

A6 During this school year, how often is this child's 

math instruction provided in his/her native 

language?

None of the time; Less than half of the time; Half of 

the time; More than half of the time; Almost all the 

time

ECLS-K

A7 Overall, how would you rate this child’s academic 

skills in math, based on curriculum standards for 

his/her current grade level?

Below grade level; About on grade level; Above 

grade level 

ECLS-K

Spring Fourth-Grade Math Teacher Questionnaire, Appendix H

Part 1: Please answer the questions in Part 1 about the child identified on the cover of this questionnaire.
A8 How often does this child work to the best of 

her/his ability in MATH?

Never; Seldom; Usually; Always

ECLS-K

A9 How many instructional groups based on 

achievement or ability levels in MATHEMATICS do 

you currently have in this child's class?

I do not use instructional groups for mathematics;

Two; Three; Four; Five or more 

ECLS-K

A10 In which mathematics instructional group is this 

child currently placed? USE "1" FOR THE HIGHEST 

INSTRUCTIONAL GROUP.

ECLS-K

Mathematics 

Instruction

From the first day of school until today, please 

indicate on how many days you have covered each 

of the following MATHEMATICS skills and concepts 

in this child's class. Please include the time during 

which you provide direct instruction as well as the 

time you spend supervising students as they work. 

Please focus on the skill areas that are shown in 

bold text. ﴾The unbolded examples are only a 

sample of things you may do or cover under this 

skill area.﴿

a. Using operations to solve problems, for 

example, solving problems by multiplying or 

dividing two whole numbers; solving multiple-step 

word problems that use several different 

operations; interpreting remainders; finding factor 

pairs; etc.

b. Using algebraic thinking, for example, solving 

word problems by representing the problem as an 

equation with a symbol for the unknown number; 

etc.

c. Understanding place value, for example, reading 

and writing multi-digit whole numbers; comparing 

two numbers based on meanings of the digits in 

each place; using understanding of place value to 

round whole numbers to any place; etc.

d. Adding and subtracting multiple-digit numbers

using strategies based on place value and 

properties of operations

Part 2: To be completed only if there is a red dot next to the child's name on the cover of this questionnaire

B1 a-h ECLS-K, updated 

to reflect 

"Common Core 

State Standards," 

corestandards.org
e. Understanding fractions, for example, 

comparing fractions with different numerators or 

denominators; adding and subtracting fractions; 

multiplying fractions by whole numbers; 

understanding the relationship between decimals 

and fractions; etc.

f. Solving problems involving measurement, for 

example, solving problems involving measures of 

distance, time, volume, or money; understanding 

the relative size of units of measurement; finding 

the area or perimeter of rectangles; etc.

g. Representing and interpreting data, for 

example, making line plots or other visuals to 

display fractions of a unit; using addition and 

subtraction of fractions to answer questions about 

a line plot; etc.

h. Drawing and identifying lines and angles, for 

example, drawing points, lines, line segments, rays, 

angles, and perpendicular and parallel lines; 

recognizing right triangles; understanding lines of 

symmetry; etc.
B2 a-l How often do the children in this class engage in 

the following mathematics activities?

a. Solve mathematics problems from textbooks or 

worksheets

b. Solve mathematics problems from the

blackboard, whiteboard/SMART Board®, or

projector

c. Solve mathematics problems in small groups or 

with a partner

d. Work with measuring instruments ﴾for example, 

rulers, compasses, protractors)

e. Work with manipulatives ﴾for example, 

geometric shapes, fraction bars﴿

f. Use a calculator

g. Take mathematics tests/quizzes

h. Write a few sentences about how to solve a

mathematics problem

i. Discuss solutions to mathematics problems with 

other students

j. Work on and discuss mathematics problems that 

reflect real-life situations

k. Use a computer for math ﴾beyond using a 

computer's calculator)

l. Create or interpret visual representations ﴾for

example, diagrams, graphs, tables, models﴿

ECLS-K, updated 

to reflect 

"Common Core 

State Standards," 

corestandards.org

Classroom and 

Student 

Characteristics

C1 a-c As of today’s date, how many children... 

a. Are currently enrolled in this class?

b. Are boys?

c. Are girls?

ECLS-K

C2 a-e What grade levels are included in this class?

a. 2nd grade or lower

b. 3rd grade

c. 4th grade

d. 5th grade

e. 6th grade or higher

ECLS-K

C3 How many of the children in this class are repeating 

their grade this year?

ECLS-K

C4 a-b How many children in this class...

a. Are classified as Gifted and Talented?

b. Are participating in a Gifted and Talented 

program?

ECLS-K

C5 How many children in this class are absent on an 

average day?

ECLS-K
C6 How many children in this class are below grade 

level, about on grade level, or above grade level in 

mathematics skills?

ECLS-K

C7 At this point in the school year, how would you rate 

the behavior of the children in this class?

Group misbehaves very frequently and is almost 

always difficult to handle; Group misbehaves 

frequently and is often difficult to handle; Group 

misbehaves occasionally; Group behaves well;

Group behaves exceptionally well.

ECLS-K

C8 a-d Items asking the percentage of the students in the 

classroom who demonstrate behaviors or 

characteristics that either disrupt or create a 

challenging learning environment. Items not 

included due to copyright restrictions (4 items 

total).

New. From Abry, 

Swanson, & 

Fabes (2012)

C9 How many children in this class have a diagnosed 

disability? 

ECLS-K

C10 Do you have any children who are English language 

learners in this class? (English language learners are 

children whose native language is one other than 

English and whose skills in listening, speaking, 

reading, or writing English are such that they have 

difficulty understanding school instruction in 

English.) 

ECLS-K

C11 How many English language learners (ELLs) do you 

have in this class?

ECLS-K

Classroom 

Instruction and 

Evaluation

D1 a-e In a typical day, how much time do children in this 

math class spend in the following activities?

a. Working independently

b. Working on individual tasks under teacher 

direction

c. Working with peers under teacher direction

d. Working in small groups with teacher

e. Teacher lecture with large group and/or large 

group discussion led by teacher 

ECLS-K:2011 

Grade 1
D2 a-b Do any of the following staff members provide 

direct instruction to students in this math class who 

are struggling or at risk of failure in math? 

INCLUDE STAFF OTHER THAN YOURSELF WHO 

PROVIDE DIRECT INSTRUCTION EITHER IN THIS 

CLASS OR IN A PULL-OUT SETTING. EXCLUDE 

PARAPROFESSIONALS/AIDES.

a. A math specialist/interventionist who has 

specialized training in MATH instruction

b. A special education teacher

Adapted from 

Reading First 

Impact Study--

Teacher Survey

D3 a-h In this class, how frequently do you or your 

students use computers or the following electronic 

devices for instructional purposes in math? Please 

include any desktop, laptop, or other computertype devices.

a. Computer ﴾desktop, laptop or other 

computer-type device such as a tablet﴿

b. LCD or DLP projector

c. Interactive whiteboard ﴾for example, SMART 

Board, Activboard﴿

d. Digital camera ﴾still or video﴿

e. CD player or MP3 player/iPod

f. DVD player or VCR

g. TV

h. Other electronic devices (PLEASE SPECIFY)

ECLS-K

D4 In an average week, how many days a week is math 

homework assigned in this math class? Please 

count homework assigned over the weekend as 

one day.

0 days; 1 day; 2 days; 3 days; 4 days; 5 days 

ECLS-K

D5 On days when homework is assigned, how much 

time do you expect children in this class to spend 

on homework in math? 

1 to 10 minutes; 11 to 20 minutes; 21 to 30 

minutes; More than 30 minutes

ECLS-K
D6 a-e In this class, how often do you use a formal 

assessment in MATH for the following purposes?

a. To evaluate how well each student is responding 

to the core curriculum provided in

the general education classroom

b. To monitor each student's progress on specific 

skills over the school year

c. To identify the deficits in specific skills of 

struggling students

d. To monitor the progress of students who fall 

below benchmark levels

e. To determine whether students need placement 

in a more or less intensive level of

instruction

ECLS-K:2011 

Grade 1

D7 a-c For each of the following statements about MATH 

indicate how strongly you agree or disagree.

a. This school has a set of clear, predetermined, 

grade-level benchmarks ﴾that is, cut

scores, goals/targets, or percentiles﴿ that are used 

to determine which students are struggling or at 

risk of failure in math in fourth grade.

b. This school has clear, predetermined criteria for 

determining the level of intervention fourth-grade 

students will receive in math.

c. This school has clear, predetermined criteria for 

determining when fourth-grade students no longer 

need a math intervention.

Adapted from 

WA (RTI) and HB 

2136: Spring 2010

Staff Activities E1 Did you participate in any professional 

development* within the last 12 months?

ECLS-K:2011 

Grade 1

E2 a-c How often did you participate in professional 

development activities covering the following 

topics in the last 12 months?

a. How to use assessment data to identify students 

who are struggling or at risk of failure in MATH

b. How to use and apply assessment data

to guide MATH instruction

c. How to implement the MATH

curriculum

Adapted from 

Reading First 

Impact Study--

Teacher Survey
E3 a-d Have you received support from any of the 

following staff members during the current 

academic year?

a. A school or district staff member whose role is to 

provide ongoing training and support to classroom 

teachers in the delivery of effective MATH 

instruction

b. A school or district staff member who provides

ongoing training and support to classroom teachers 

in the delivery of effective behavioral supports

c. A school or district staff member who supports 

teachers in collecting, organizing, and managing 

assessment

d. A school or district staff member who supports

teachers in the interpretation and use of 

assessment data to guide instruction

ECLS-K:11 Grade 1

E4 Date Questionnaire Completed:
Construct

Research 

Question

Grade/class configuration TQ1

Family mobility TQ3

Attendance TQ3; TQ5

Receipt of remedial or gifted 

services

TQ3; TQ7

Native language other than English TQ2; TQ3

Receipt of instruction for English 

language learners

TQ2; TQ3

Comparison to peers: academic 

skills for current grade level in 

math

TQ5

questionnaire.
Working to the best of one's 

ability

TQ5

Use of achievement grouping: 

mathematics

TQ1; TQ3

Placement in achievement 

grouping: mathematics

TQ5

his questionnaire

Time spent on specific activities 

and skills in mathematics

TQ7

Time spent on specific activities 

and skills in mathematics

TQ7

Classroom characteristics: 

enrollment, gender distribution

TQ1; TQ2

Classroom characteristics: grade 

levels within class

TQ2

Classroom characteristics: 

number of repeaters

TQ2; TQ3

Classroom characteristics: 

number of gifted and talented

TQ3

Students above or below grade 

level

TQ3
Student absenteeism TQ2

Overall behavior of the class TQ2; TQ5

Classroom climate (student 

difficulties)

TQ2; TQ5

Number of students with 

disabilities

TQ3

Number of English language 

learners

TQ3

Number of English language 

learners

TQ3

Proportion of time students 

spend working independently, 

small group, large group

TQ1
Response to Intervention-related 

policies and practices

TQ6

Availability, use, and adequacy of 

resources

TQ1

Use of homework TQ1

Use of homework TQ1
Response to Intervention-related 

policies and practices

TQ6

Response to Intervention-related 

policies and practices

TQ6

Professional development 

activities

TQ4

Response to Intervention-related 

policies and practices

TQ6
Response to Intervention-related 

policies and practices

TQ6

N/A N/A
Section Item # Item Stem Source

Student 

Information

A1 a-d Are you this child's primary teacher in the following 

subject areas? 

a. Reading/language arts

b. Mathematics

c. Science

d. Social studies

ECLS-K

A2 How long has this child been in your science class 

this school year until now? 

Entire school year until now; More than one 

semester but less than the entire school year until 

now; More than one quarter but less than one 

semester; Less than one quarter of the school year

ECLS-K

A3 Please indicate the total number of times this child 

has been absent from your science class during the 

current school year.

No absences; 1 to 4 absences; 5 to 7 absences; 8 to 

10 absences; 11 to 19 absences; 20 or more 

absences 

ECLS-K

A4 Is English this child's native language? ECLS-K

A5 During this school year, how often is this child's 

science instruction provided in his/her native 

language?

None of the time; Less than half of the time; Half of 

the time; More than half of the time; Almost all the 

time

ECLS-K

A6 Overall, how would you rate this child’s academic 

skills in SCIENCE, based on curriculum standards for 

his/her current grade level?

Below grade level; About on grade level; Above 

grade level 

ECLS-K

A7 How often does this child work to the best of 

his/her ability in SCIENCE?

Never; Seldom; Usually; Always

ECLS-K

Spring Fourth-Grade Science Teacher Questionnaire, Appendix H

Part 1: Please answer the questions in Part 1 about the child identified on the cover of this questionnaire.

Part 2: To be completed only if there is a red dot next to the child's name on the 
From the first day of school until today, please 

indicate on how many days you have covered each 

of the following SCIENCE skills and concepts in this 

child's class. Please include the time during which 

you provide direct instruction as well as the time 

you spend supervising students as they work. 

Please focus on the skill areas that are shown in 

bold text. ﴾The unbolded examples are only a 

sample of things you may do or cover under this 

skill area.﴿

Fields of Science

a. Physical science, for example, understanding

electricity, magnetism, energy, waves, chemistry, 

etc.

b. Life science, for example, learning about

organisms, life cycles, food chains,

ecosystems, etc.

c. Earth science, for example, learning about

rocks and minerals, weather, erosion, water,

volcanoes, earthquakes, etc.

Scientific Method

d. Observations and hypotheses, for example, 

understanding the difference between

observations and inferences, formulating

predictions that can be tested, etc.

e. Scientific testing, for example, planning and

conducting investigations, measuring using

appropriate tools, demonstrating safe behavior, etc.

f. Analysis and conclusions, for example, analyzing 

the results of a scientific investigation and 

determining whether the results support the initial 

prediction, etc.

Science, Engineering and Technology

g. Interdependence of science, technology and 

engineering, for example, exploring how scientific 

discoveries lead to the development of new 

technologies, new technologies lead to new 

scientific discoveries, etc.

h. Engineering concepts, for example, identifying a 

simple design problem that can be solved through 

the development of an object, tool, process, or 

system; etc.

Science Instruction B1 a-h ECLS-K, updated 

to reflect 

"Common Core 

State Standards," 

corestandards.org
B2 a-l How often do the children in this class engage in 

the following science activities?

a. Read a science textbook

b. Discuss science in the news

c. Generate and test hypotheses

d. Work with other children on a science activity or

project

e. Use science equipment ﴾e.g., magnifying glass,

scales, thermometers﴿

f. Prepare a written science report

g. Engage in hands-on activities or investigations

in science

h. Talk about measurements and results from

children’s hands-on activities

i. Take a science test or quiz

j. Use library resources for science

k. Use computers for science

l. Use the Internet for science

ECLS-K, updated 

to reflect 

"Common Core 

State Standards," 

corestandards.org

Classroom and 

Student 

Characteristics

C1 a-c As of today’s date, how many children... 

a. Are currently enrolled in this class? 

b. Are boys? 

c. Are girls?

ECLS-K

C2 a-e What grade levels are included in this class?

a. 2nd grade or lower

b. 3rd grade

c. 4th grade

d. 5th grade

e. 6th grade or higher

ECLS-K

C3 How many of the children in this class are repeating 

their grade this year?

ECLS-K

C4 a-b How many children in this class...

a. Are classified as Gifted and Talented? 

b. Are participating in a Gifted and Talented 

program?

ECLS-K

C5 How many children in this class are absent on an 

average day?

ECLS-K

C6 How many children in this class are below grade 

level, about on grade level, or above grade level in 

science skills?

ECLS-K
C7 At this point in the school year, how would you rate

the behavior of the children in this class?

Group misbehaves very frequently and is almost

always difficult to handle; Group misbehaves

frequently and is often difficult to handle; Group

misbehaves occasionally; Group behaves well;

Group behaves exceptionally well.

ECLS-K

C8 Items asking the percentage of the students in the 

classroom who demonstrate behaviors or 

characteristics that either disrupt or create a 

challenging learning environment. Items not 

included due to copyright restrictions (4 items 

total).

New. From Abry, 

Swanson, & Fabes 

(2012)

C9 How many children in this class have a diagnosed 

disability? 

ECLS-K

C10 Do you have any children who are English language 

learners in this class? (English language learners are 

children whose native language is one other than 

English and whose skills in listening, speaking, 

reading, or writing English are such that they have 

difficulty understanding school instruction in 

English.) 

ECLS-K

C11 How many English language learners (ELLs) do you 

have in this class?

ECLS-K

Classroom 

Instruction and 

Evaluation

D1 a-e In a typical day, how much time do children in this 

science class spend in the following activities? 

a. Working independently

b. Working on individual tasks under teacher 

direction

c. Working with peers under teacher direction

d. Working in small groups with teacher

e. Teacher lecture with large group and/or large 

group discussion led by teacher

ECLS-K:2011 

Grade 1
D2 a-b Do any of the following staff members provide 

direct instruction to students in this science class 

who are struggling or at risk of failure in science? 

INCLUDE STAFF OTHER THAN YOURSELF WHO 

PROVIDE DIRECT INSTRUCTION EITHER IN THIS 

CLASS OR IN A PULL-OUT SETTING. EXCLUDE 

PARAPROFESSIONALS/AIDES.

a. A SCIENCE specialist/interventionist who has 

specialized training in science instruction

b. A special education teacher 

Adapted from 

Reading First 

Impact Study--

Teacher Survey

D3 a-h In this class, how frequently do you or your 

students use computers or the following electronic 

devices for instructional purposes in science? 

Please include any desktop, laptop, or other 

computer-type devices.

a. Computer ﴾desktop, laptop or other 

computer-type device such as a tablet﴿

b. LCD or DLP projector

c. Interactive whiteboard ﴾for example, SMART 

Board, Activboard﴿

d. Digital camera ﴾still or video﴿

e. CD player or MP3 player/iPod

f. DVD player or VCR

g. TV

h. Other electronic devices (PLEASE SPECIFY)

ECLS-K

D4 In an average week, how many days a week is 

science homework assigned in this class? Please 

count homework assigned over the weekend as 

one day.

0 days; 1 day; 2 days; 3 days; 4 days; 5 days; 

ECLS-K

D5 On days when homework is assigned, how much 

time do you expect children in this class to spend 

on homework in science?

1 to 10 minutes; 11 to 20 minutes; 21 to 30 

minutes; More than 30 minutes

ECLS-K
D6 a-e In this class, how often do you use a formal 

assessment in SCIENCE for the following purposes?

a. To evaluate how well each student is responding 

to the core curriculum provided in the general 

education classroom

b. To monitor each student's progress on specific 

skills over the school year

c. To identify the deficits in specific skills of 

struggling students

d. To monitor the progress of students who fall 

below benchmark levels

e. To determine whether students need placement 

in a more or less intensive level of

instruction

ECLS-K:2011 

Grade 1

D7 a-c For each of the following statements about 

SCIENCE indicate how strongly you agree or 

disagree.

a. This school has a set of clear, predetermined, 

grade-level benchmarks ﴾that is, cut scores, 

goals/targets, or percentiles﴿ that are used to

determine which students are struggling or at risk 

of failure in science in fourth grade.

b. This school has clear, predetermined criteria for

determining the level of intervention fourth-grade

students will receive in science.

c. This school has clear, predetermined criteria for

determining when fourth-grade students no longer

need a science intervention.

Adapted from WA 

(RTI) and HB 

2136: Spring 2010

Staff Activities E1 Did you participate in any professional 

development* within the last 12 months?

ECLS-K:2011 

Grade 1

E2 a-c How often did you participate in professional 

development activities covering the following 

topics in the last 12 months?

a. How to use assessment data to identify students 

who are struggling or at risk of failure in SCIENCE

b. How to use and apply assessment data

to guide SCIENCE instruction

c. How to implement the SCIENCE

curriculum

Adapted from 

Reading First 

Impact Study--

Teacher Survey
E3 a-d Have you received support from any of the 

following staff members during the current 

academic year?

a. A school or district staff member whose role is to 

provide ongoing training and support to classroom 

teachers in the delivery of effective SCIENCE 

instruction

b. A school or district staff member who provides 

ongoing training and support to classroom teachers

c. A school or district staff member who supports 

teachers in collecting, organizing, and managing 

assessment data

d. A school or district staff member who supports 

teachers in the interpretation and use of 

assessment data to guide instruction

ECLS-K:11 Grade 1

E4 Date Questionnaire Completed:
Construct

Research 

Question

Grade/class configuration TQ1

Family mobility TQ3

Attendance TQ3; TQ5

Native language other than English TQ2; TQ3

Receipt of instruction for English 

language learners

TQ2; TQ3

Comparison to peers: academic 

skills for current grade level in 

science

TQ5

Working to the best of one's 

ability

TQ5

uestionnaire.
Time spent on specific activities 

and skills in science

TQ7
Time spent on specific activities 

and skills in science

TQ7

Classroom characteristics: 

enrollment, gender distribution

TQ1; TQ2

Classroom characteristics: grade 

levels within class

TQ2

Classroom characteristics: 

number of repeaters

TQ2; TQ3

Classroom characteristics: 

number of gifted and talented

TQ3

Student absenteeism TQ3

Students above or below grade 

level in science

TQ2
Overall behavior of the class TQ2; TQ5

Classroom climate (student 

difficulties)

TQ2; TQ5

Number of students with 

disabilities

TQ3

Number of English language 

learners

TQ3

Number of English language 

learners

TQ3

Proportion of time students 

spend working independently, 

small group, large group

TQ1
Response to Intervention-related 

policies and practices

TQ6

Availability, use, and adequacy of 

resources

TQ1

Use of homework TQ1

Use of homework TQ1
Response to Intervention-related 

policies and practices

TQ7

Response to Intervention-related 

policies and practices

TQ6

Professional development 

activities

TQ4

Professional development 

activities; Response to 

Intervention-related policies and 

practices

TQ6
Response to Intervention-related 

policies and practices

TQ6

N/A
Item # Item Stem Source

1 What is your gender? ECLS-K

2 In what year were you born? ECLS-K

3 Are you Hispanic or Latino? ECLS-K

4 Which best describes your race? MARK ONE OR MORE 

RESPONSES TO INDICATE WHAT YOU CONSIDER YOURSELF TO 

BE.

 American Indian or Alaska Native; Asian; Black or African 

American; Native Hawaiian or Other Pacific Islander; White

ECLS-K

5 What is the highest level of education you have completed?

Did not complete high school; High school diploma or 

equivalent/GED; Some college or technical or vocational 

school; Associate’s degree; Bachelor's degree; Master's 

degree; An advanced professional degree beyond a master’s 

degree ﴾for example, Ph.D., MD﴿

ECLS-K

6 Is this school year the first year you have worked with children 

in this school?

ECLSK:2011

7 Counting this school year, how many total years have you 

been working with children receiving special education or 

related services in any school, including years in which you 

worked part time?

ECLS-K

8 Counting this school year, how many total years have you 

been working with children in any school, including years in 

which you worked part time? This would include other

assignments such as teaching in a regular classroom or 

otherwise providing services to children.

ECLS-K

Spring Fourth-Grade Special Education Teacher Teacher-Level Questionnaire, Appendix H
9 a-m Which of the following credentials, licenses, or certificates do 

you have for working with children with disabilities? DO NOT 

INCLUDE ACADEMIC DEGREES, SUCH AS A BACHELOR'S 

DEGREE, MASTER'S DEGREE OR PH.D.

a. Emergency credential

b. Provisional or temporary credential

c. Disability-specific credential or endorsement

d. Special education credential or endorsement ﴾for more 

than one disability category﴿

e. General education credential

f. Speech/language therapy state license or certification

g. Physical therapy state license or certification

h. Occupational therapy state license or certification

i. Social work license or certification

j. School psychology license or certification

k. Clinical psychology license or certification

l. Certificate of Clinical Competence

m. Other professional license, credential, or endorsement

﴾PLEASE SPECIFY﴿

ECLS-K

10 Have you taken the exam for National Board for Professional 

Teaching Standards certification?

Not taken; Taken and passed; Taken and have not yet passed;

Taken and awaiting test results; Not applicable 

ECLS-K
11 a-r Have you ever taken a college course in the following areas?

a. Early childhood education

b. Early childhood special education

c. Elementary education

d. Child development

e. English as a Second Language ﴾ESL﴿ or teaching English

language learners

f. General special education

g. Learning disabilities

h. Intellectual disability *

i. Orthopedic impairments

j. Serious emotional disturbance

k. Deafness and hearing

l. Blindness and vision

m. Communication disorders

n. Infants and toddlers with disabilities

o. Physical therapy

p. Occupational therapy

q. School psychology

r. Classroom management

ECLS-K

12 a-d Have you ever taken a college course that addressed issues 

related to the following?

a. Using published research evidence to identify and select 

effective interventions and supports for students

b. Using formal assessment data to inform the choice of 

READING interventions and supports for students

c. Using formal assessment data to inform the choice of MATH 

interventions and supports for students

d. Using data to inform the choice of behavioral interventions 

and supports for students

ECLSK:2011 

Grade 1

13 Which of the following best describes your current position in 

this school?

Special education teacher; Special education teacher 

consultant; General education teacher; Special education 

classroom aide; Speech-language pathologist; Physical 

therapist; Physical therapy assistant or aide; Occupational 

therapist; Occupational therapy assistant or aide; School 

psychologist; School counselor; School social worker;

Other ﴾PLEASE SPECIFY﴿

ECLS-K
14 How do you classify your main assignment at this school, that 

is, the activity at which you spend most of your time during 

this school year? 

Regular full-time teacher/service provider; Regular part-time 

teacher/service provider; Itinerant teacher/service provider 

﴾that is, your assignment requires you to provide 

instruction/related services at more than one school); 

Long-term substitute ﴾that is, your assignment requires that 

you fill the role of a teacher on a long-term basis, but you are 

still considered a substitute); Teacher aide; Other ﴾PLEASE 

SPECIFY﴿

ECLS-K

15 a-e During this school year, where have you worked with children 

with IEPs? INCLUDE ONLY CHILDREN WHO ATTEND THIS 

SCHOOL.

a. In a general education classroom

b. In a special education classroom

c. In a non-classroom space ﴾for example, office, therapy

room, small work space, mobile van, etc.﴿

d. In a location outside of the school setting ﴾for example, a 

child's home, a private clinic, etc.﴿

e. Other ﴾PLEASE SPECIFY﴿

ECLS-K

16 a-d Please indicate the extent to which you agree or disagree with 

each of the following statements.

a. I really enjoy my present job.

b. I am certain I am making a difference in the lives of the

children I work with.

c. If I could start over, I would choose this career again.

d. I am satisfied with my class size/caseload.

ECLS-K

17 During the school year, how many children with IEPs have you 

worked with or provided services for, on average, each week? 

(Include children you work with directly, as well as children for 

whom you consult with the general education teacher and/or 

another special education teacher/service provider? 

1-10; 11-20; 21-40; More than 40; Don't know

ECLS-K

18 Date questionnaire completed:
Construct

Research 

Question

Teacher demographic information SEQ4

Teacher demographic information SEQ4

Teacher demographic information SEQ4

Teacher demographic information SEQ4

Teacher’s education SEQ4

First year teaching in current school SEQ4

Teaching experience in special 

education

SEQ4

Total years teaching experience SEQ4

Level Questionnaire, Appendix H
Teaching certification, credentials, 

and licenses

SEQ4

Teaching certification, credentials, 

and licenses

SEQ4
Teacher’s education SEQ4

Teacher’s education; Response to 

Intervention-related practices

SEQ4

Teaching position and assignment SEQ4
Teaching position and assignment SEQ4

Locations in which teacher delivers 

services

SEQ1, SEQ3, 

SEQ5

Teacher’s sense of efficacy; Job 

satisfaction

SEQ4

Teaching student caseload SEQ4, SEQ5

N/A
Item # Item Stem Source

1 Is this child currently receiving gifted/talented services through an IEP, or has the 

child received such services during this school year?

ECLS-K

2 Is this child currently receiving special education services through an IEP due to a 

disability or has the child received such services during this school year?

ECLS-K

3 a-f In what capacity or capacities do you teach or provide services to this child?

a. Provide instruction directly to the child

b. Provide related services directly to the child

c. Provide consultation services directly to the child

d.Provide indirect consultation services ﴾for example, consultation to the child's 

teacher﴿

e. Provide case management

f. Other ﴾PLEASE SPECIFY﴿

ECLS-K

4 When was this child first determined eligible for special education or related 

services?

Before kindergarten; During kindergarten; During first grade; During second grade; 

During third grade; During fourth grade; Other ﴾PLEASE SPECIFY﴿;

Don't know

ECLS-K

5 Is this the first school year that the child has been receiving special education 

services?

ECLS-K

6 When did this child first start receiving special education or related services?

Before kindergarten; During kindergarten; During first grade; During second grade; 

During third grade; Other (PLEASE SPECIFY); Don't know

ECLS-K

7 To what extent were you involved in planning the transition from last year's 

special education program to this year's special education program for this child?

Not at all; Somewhat; Extensively

ECLS-K

8 To what extent did you communicate with the person(s) who provided special 

education for this child last year?

Not at all; Somewhat; Extensively; I provided special education for this child last 

year.

ECLS-K

9 Have you reviewed this child’s records related to special education services 

provided before this school year?

Yes; No, I don't have access to the records; No, I have access to the records, but 

have not reviewed them; No, I provided special education to this child last year

ECLS-K

Spring Fourth-Grade Special Education Teacher Child-Level Questionnaire, Appendix H
10 What is this child’s primary disability as identified on the child’s IEP? PLEASE 

SELECT THE CATEGORY BELOW INTO WHICH THE CHILD'S PRIMARY DISABILITY 

FITS BEST.

Speech or language impairments; Specific learning disabilities; Emotional 

disturbance; Intellectual disability *; Developmental delay; Visual impairments 

﴾including blindness﴿; Hearing impairments ﴾including deafness﴿; Orthopedic 

impairments; Other health impairments; Autism; Traumatic brain injury;

Deaf-blindness; Multiple disabilities (children included in this categry should be 

those who have more than one primary disability which do not include deafblindness or developmental delay); No classification is given

ECLS-K

11 a-n During this school year, for which of the following disabilities has this child 

received special education or related services, whether for the child’s primary 

disability or another of his/her disabilities?

a. Speech or language impairments

b. Specific learning disabilities

c. Emotional disturbance

d. Intellectual disability *

e. Developmental delay

f. Visual impairments ﴾including blindness﴿

g. Hearing impairments ﴾including deafness﴿

h. Orthopedic impairments

i. Other health impairments

j. Autism

k. Traumatic brain injury

l. Deaf-blindness

m. Multiple disabilities (children included in this category should be those who 

have more than one primary disability which do not include deaf-blindness or 

developmental delay)

n. No classification given.

ECLS-K

12 During this school year, has this child received any special education or related 

services because of a diagnosed Attention Deficit Disorder (ADD) or Attention 

Deficit Hyperactivity Disorder (ADHD)?

ECLS-K

THE REST OF THE ITEMS IN THIS QUESTIONNAIRE REFER TO THIS CHILD'S SPECIAL EDUCATION EXPERIENCE DURING THE CU
13 a-p During this school year, which of the following describe(s) the IEP goals for this 

child?

Academics

a. Reading

b. Mathematics

c. Language Arts

d. Science

Speech and language

e. Auditory processing

f. Listening comprehension

g. Oral expression

h. Voice/speech articulation

i. Language pragmatics

Social

j. Social skills

k. General appropriateness of behavior

Life skills

l. Adaptive behavior or self-help skills

Physical/Mobility

m. Fine motor skills

n. Gross motor skills

o. Orientation and mobility

Other

p. Other (PLEASE SPECIFY) 

ECLS-K

14 a-m During this school year, which of the following related services have been 

provided through the school to this child?

a. Audiology

b. Counseling services

c. Occupational therapy

d. Physical therapy

e. Psychological services

f. Health services

g. Social work services

h. Special transportation

i. Speech or language therapy

j. Orientation services

k. Mobility services

l. Rehabilitation services

m. Other ﴾PLEASE SPECIFY﴿

ECLS-K
15 a-n During this school year, has this child received any of the following?

a. Adaptive physical education

b. Assistance from classroom aides ﴾for example, teacher aide,

behavioral assistant, special education aide﴿

c. Interpreter for the deaf or hard of hearing ﴾oral or sign﴿

d. Teacher used Braille to provide instruction

e. Child was taught how to use Braille

f. Teacher used American Sign Language to provide instruction

g. Child was taught how to use American Sign Language

h. Teacher used Manual English to provide instruction

i. Child was taught how to use Manual English

j. Teacher used Cued Speech to provide instruction

k. Child was taught how to use Cued Speech

l. Mental health services, personal/group counseling, therapy, or

psychiatric care provided to the child

m. Tutoring/remediation from special education teacher

n. Training, counseling, and other supports/services provided to

this child's family

ECLS-K

16 During this school year, has this child’s primary placement been a general 

education classroom? 

ECLS-K

17 During this school year, approximately how many hours per week of direct special 

education and related services (that is, service provided directly to the child, from 

a teacher or another adult) has this child received?

ECLS-K

18 Of the hours of direct special education and related services reported above, 

approximately how many of those hours per week were the instruction/services 

provided outside of a general education classroom but within the school setting? 

ECLS-K

19 a-l During this school year, what teaching practices and methods have you and/or 

other special education service providers used with this child?

a. One-on-one instruction

b. Small-group instruction

c. Large-group instruction

d. Co-teaching ﴾see definition above﴿

e. Cooperative learning

f. Peer tutoring

g. Computer-based instruction

h. Direct instruction

i. Cognitive strategies

j. Self-management

k. Behavior management

l. Instruction received through a sign interpreter

ECLS-K
20 During this school year, which of the following best describes the curriculum 

materials used with this child in the general education classroom?

General education curriculum materials were used without modification; General 

education curriculum materials were used with some modifications;

General education curriculum materials were used with substantial modifications; 

Specially-designed commercial materials were used; Teacher-designed materials 

were used; Child not in this setting; Don't know

ECLS-K

21 During this school year, which of the following best describes the curriculum 

materials used with this child in the special education classroom/program?

General education curriculum materials were used without modification;

General education curriculum materials were used with some modifications;

General education curriculum materials were used with substantial modifications; 

Specially-designed commercial materials were used; Teacher-designed materials 

were used; Child not in this setting; Don't know

ECLS-K

22 During this school year, has this child had the assistance of a service animal while 

at school? A SERVICE ANIMAL IS ANY GUIDE DOG, SIGNAL DOG, OR OTHER DOG 

INDIVIDUALLY TRAINED TO PROVIDE ASSISTANCE TO AN INDIVIDUAL WITH A 

DISABILITY. SERVICE ANIMALS CAN BE USED FULL TIME OR IN-SCHOOL ONLY AS 

PART OF A PROGRAM SUCH AS ANIMAL ASSISTED THERAPY (AAT).

Yes, this child has been assisted by his/her own service dog at school; 

Yes, this child has been assisted by a service dog provided by a school program;

No, this child has not been assisted by a service dog at school;

ECLS-K:2011
During this school year, which of the following assistive technologies and devices 

has this child used?

Mobility aids

a. Vans, vehicles

b. Wheelchair

c. Walker

d. White cane

Communication aids

e. Electronic with voice output ﴾for example, Touch Talker﴿

f. Electronic without voice output ﴾for example, device with visual display or 

printed speech output﴿

g. Non-electronic ﴾for example, manual printing board﴿

Hearing assistance

h. Hearing aids

i. FM loops

j. TTYs/TDDs

k. Cochlear implants

l. Real-time captioning

Visual aids

m. Braille texts

n. Electronic Braille devices

o. Digital texts

p. Magnifying devices

q. Close-captioned television ﴾CCTV﴿

Learning aids (non-computer)

r. Tape recorder

s. Calculator

t. Electronic spelling devices

Computer hardware designed or adapted for children with disabilities (for 

example, alternate keyboards, switch interface)

u. Used solely by individual child

v. Shared with other children

Computer software designed for children with disabilities

w. Reading

x. Writing

y. Mathematics

Other assistive technologies or devices

z. Other (PLEASE SPECIFY)

24 Does this child have a computer, laptop, or word processing device assigned to 

him/her for use full time this school year? 

ECLS-K

23 a-z ECLS-K
25 During this school year, on average, how often have you met with general 

education teacher﴾s﴿ to discuss this child's program or progress?

Not applicable because I am the child's general education teacher; Not applicable 

to my work with this child; Every day or several times a week;

Once a week or several times a month; Once a month; A few times over the 

school year; Once during this school year; Never during this school year

ECLS-K

26 On average, how long were the meetings with the general education teacher﴾s﴿ to 

discuss this child's program or progress?

1 to 15 minutes ; 16 to 30 minutes; 31 to 45 minutes; 46 to 60 minutes; More 

than 60 minutes

ECLS-K

27 During this school year, approximately how often have you communicated with 

this child's parents about this child's program or progress ﴾by phone, in person, or 

in writing, including e-mail﴿?

Every day or several times a week; Once a week or several times a month; Once a 

month; A few times over the school year; Once during this school year; Never 

during this school year

ECLS-K

28 a-h During this school year, has this child received formal individual evaluations in any 

of the following areas for purposes of developing IEP goals?

a. Psychological

b. Speech/language

c. Vision

d. Hearing

e. Learning style

f. Motor skills

g. Academics

h. Other ﴾PLEASE SPECIFY﴿

ECLS-K

29 To what extent is this child expected to achieve the same general education goals 

as other children at his/her grade level this school year?

Child is expected to attain grade level achievement for all of the academic content 

standards; Child is expected to attain grade level achievement for some of the 

academic content standards; Child is expected to attain grade level achievement 

for only a few of the academic content standards; Child is not expected to attain 

grade level achievement for any of the academic content standards; There are no 

academic content standards at this grade level; Don't know

ECLS-K

30 What percentage of this child's current IEP goals have been met or nearly met at 

this point in the school year? 

76 to 100 percent; 51 to 75 percent; 26 to 50 percent; 1 to 25 percent; 

0 percent

ECLS-K
31 Which of the following best expresses the likelihood that this child will continue to 

receive some level of special education services ﴾through an IEP﴿ in the next 

school year? 

Definitely will continue in special education; Very likely to continue in special 

education; Rather likely to continue in special education; Rather unlikely to 

continue in special education; Very unlikely to continue in special education; 

Definitely will not continue in special education (will be dismissed from services)

ECLS-K

32 During this school year, to what extent has this child participated in any 

grade-level assessment administered as part of the school's testing program?

Child did not participate in the school's testing or assessment program; Child 

participated in alternate assessments and no regular assessments; Child 

participated in some alternate assessments and some regular assessments; 

Child participated fully in the school's regular testing or assessment program;

There is no testing or assessment program at this grade level; Don't know

ECLS-K

33 Did this child receive special accommodations to participate in the school's regular 

testing or assessment program this school year?

ECLS-K

34 In which grade is this child enrolled?

Kindergarten; First grade; Second grade; Third grade; Fourth grade; Fifth grade or 

higher; This child is in an ungraded classroom

ECLS-K

35 Date Questionnaire Completed:
Construct Research 

Question

Child's receipt of services: 

gifted/talented

SEQ1

Child's receipt of services: special 

education

SEQ1

Type of special education services SEQ1

Length of diagnosis and services SEQ7

Age/Grade of first IEP and services for 

child

SEQ7

Age/Grade of first IEP and services for 

child

SEQ7

Transition activities SEQ1

Transition activities SEQ1

Transition activities SEQ1

Appendix H
Child’s disability SEQ2

Child’s disability SEQ2

Child's disability SEQ2

DURING THE CURRENT SCHOOL YEAR.
IEP goals SEQ5

Type of special education services SEQ1, SEQ2
Type of special education services SEQ1, SEQ2

Child’s classroom placement SEQ1;SEQ3, 

SEQ5

Frequency of special education services SEQ1

Frequency of special education services: 

outside general education classroom

SEQ1, SEQ3

Teaching methods and materials SEQ1, SEQ2
Teaching methods and materials SEQ1, SEQ2

Teaching methods and materials SEQ1, SEQ2

Teaching methods and materials: 

assistive technology

SEQ1, SEQ2
Teaching methods and materials: 

assistive technology

SEQ5, SEQ7

Teaching methods and materials: 

assistive technology

SEQ2, SEQ5
Staff communication SEQ5, SEQ7

Staff communication SEQ5, SEQ7

Parent communication SEQ6

Participation in assessment TQ3, SEQ5, 

SEQ7

Expectation for achievement of general 

education goals

TQ3, SEQ5

IEP goal achievement SEQ1; SEQ7
IEP goal achievement TQ3, SEQ7

Participation in assessment TQ3, SEQ3, 

SEQ5

Participation in assessment: special 

accommodations

TQ3, SEQ3, 

SEQ5

Current grade level N/A

N/A N/A
Section Item #

School 

Characteristics

A1

A3

A4

A6

A7

Spring Fourth-Grade School Administrator Questionnaire For New Schools, Appendix H

A2 a-d

A5
A9

A11

School-Family- B1 a-f

Community 

Connections

B2 a-b

A10 a-c

A8 a-h
B3

B4

B7 a-i

B6 a-f

B8 a-g

B5 a-b
B11

B12

School Policies 

and Practices

C1

C2

C3

B10 a-k

B9 a-f

C4 a-d
C5

C7

C9

C11

School 

Programs for 

Particular 

Populations

D1

C10 a-b

C8 a-d

C6 a-d
D2

D3

D5

D6

D8 a-e

D7a-b

D4 a-c
D9

Federal 

Programs: Title 

I, Adequate 

Yearly Progress, 

and Title III

E1

E2

E3

E4

E5

F2 a-h

Staffing and 

Teacher 

Characteristics

F1 a-f
F6

F7

F8

School 

Administrator 

Characteristics

G1

G2

F5 a-b

F3 a-e

F4 a-b
G3

G4

G7

G9

G10

G8 a-f

G6 a-f

G5 a-c
G11

G12

G13

G14
Item Stem Source

How many instructional days will this school provide during this academic year? IF THIS IS 

A YEAR-ROUND SCHOOL, PLEASE PROVIDE THE NUMBER OF INSTRUCTIONAL DAYS A GIVEN 

CHILD WOULD ATTEND.C15

ECLS-K

School enrollment. WRITE IN THE APPROXIMATE NUMBER OF CHILDREN FOR EACH OF THE 

FOLLOWING.

a. Total enrollment in fourth grade in your school around October 1, 2014, or the date 

nearest to that for which data are available

b. Total enrollment for your school (across all grades) around October 1, 2014, or the date 

nearest to that for which data are available

c. Number of children who have enrolled in your school Sicne October 1, 2014

d. Number of children who have left your school since October 1, 2014, and have not 

returned

Approximately, what is the Average Daily Attendance for your school this year? WRITE IN 

PERCENT OR NUMBER BELOW. TO CALCULATE PERCENT, DIVIDE THE NUMBER OF 

STUDENTS ATTENDING ON AN AVERAGE DAY BY THE NUMBER OF STUDENTS ENROLLED 

AND THEN MULTIPLY BY 100.

ECLS-K

Mark all grade levels included in your school. ECLS-K

Which of the following characterizes your school? MARK ALL THAT APPLY.

Regular public school (not including magnet school)

Public magnet school

Charter school

Catholic school: Diocesan; Parish; Private order

Other private school, religious affiliation

Private school affiliated with NAIS, no religious affiliation

Other private school, no religious or NAIS affiliation

Early childhood center (school/center includes preschool and/or early grades)

Special education school -- primarily serves chldren with disabilities

Year-round school

Bureau of Indian Education (BIE) or tribal school

IF YOU MARKED "CHARTER SCHOOL" IN Q 15, GO TO Q A6. IF YOU DID NOT MARK 

"CHARTER SCHOOL," THEN SKIP TO Q A8.

In what year did this school start providing instruction as a public CHARTER school? ECLS-K

Which of the following characterizes your public CHARTER school? For profit; Not for profit ECLS-K

rth-Grade School Administrator Questionnaire For New Schools, Appendix H

ECLS-K

ECLS-K
Approximately how many or what percentage of the children in your school belongs to 

each of the following racial/ethnic groups? COMPLETE EITHER THE NUMBER OR PERCENT 

COLUMN. ENTER "0" IF YOUR SCHOOL HAS NO CHILDREN IN THAT RACIAL/ETHNIC GROUP. 

 THE NUMBER COLUMN SHOUD ADD TO YOUR TOTAL SCHOOL ENROLLMENT OR THE 

PERCENT COLUMN SHOULD ADD TO 100%.

a. Hispanic/Latino of any race

b. American Indian or Alaska Native, not Hispanic or Latino

c. Asian, not Hispanic or Latino

d. Black or African American, not Hispanic or Latino

e. Native Hawaiian or Other Pacific Islander, not Hispanic or Latino

f. White, not Hispanic or Latino

g. Two or more races, not Hispanic or Latino

h. Total school enrollment (sum of a through g)

If your school is a private, magnet, or charter school, please check here and SKIP TO Q A11. ECLS-K:2011 

Grade 1

About what percentage of the children enrolled in this school attend from outside of this 

school’s assigned attendance area because....

a. They have special needs (gifted and talented, children with disabilities, etc.) and attend 

to receive a specialized program or service?

b. They transferred into the school because their previous school did not make adequate 

yearly progress (AYP)? (Adequate yearly progress is your state's measure of yearly 

progress toward achieving state academic standards.)

c. They attend this school under public school choice for reasons other than their assigned 

school did not make AYP (that is, excluding those who are reported in b)?

About what percentage of the children enrolled in this school are eligible for free or 

reduced-price lunch?

ECLS-K 

Please indicate how often each of the following activities is provided by your school. 

a. PTA, PTO, or Parent-Teacher-Student organization meetings

b. Reports (report cards) of chldren's performance provided to parents

c. Information on the child's standardized assessment scores provided to parents

d. Teacher-parent conferences

e. School performances to which parents are invited

f. Classroom programs like class plays, book nights, or family math nights

During this school year, how often has your school used the following ways to 

communicate with all parents?

a. Electronic communication to all parents, such as group emails, electronic newsletters, 

website postings, "robocalls" (mass automated phone calls), text alerts, or other electronic 

notices for all parents

b. Non-electronic communications to all parents, such as letters, newsletters, phone calls, 

or other non-electronic messages for all parents

ECLS-K

ECLS-K:2011

ECLS-K

ECLS-K
During this school year, has your school used an online tool or website that is available to 

the general public and that parents can access without a login or password?

ECLS-K:2011

During this school year, has your school (or any teacher)) used an online tool or website 

that parents can only access with a login or password to get information about their child, 

the child's class, or the school?

ECLS-K:2011

Have the following types of information been provided in the online tool or website that 

parents can only access with a login and password?

a. Classroom-specific assignments, including homework

b. Child- or parent-specific information, such as progress reports between grading periods

How much of a problem are the following in the neighborhood where this school is 

located? 

a. Tensions based on dracial, ethnic, or religious differences

b. Selling or using drugs or excessive drinking in public

c. Gangs

d. Vacant houses and buildings

e. Crime in the neighborhood

f. Violence in the neighborhood

To the best of your knowledge how often do the following types of problems occur at your 

school?

a. Children bringing weapons to school

b. Theft

c. Physical conflicts among students

d. Children bringing in or using alcohol at school

e. Children bringing in or using illegal drugs at school

f. Vandalism of school property

g. Student bullying

h. Widespread disorder in classrooms

i. Class cutting

Does your school take any of the following measures to ensure the safety of children?

a. Security guards, unarmed

b. Security guards, armed

c. Metal detectors

d. Locked doors during the school day

e. A requirement that visitors sign in

f. Intercoms or telephones in classrooms

g. Other (PLEASE SPECIFY)

ECLS-K

ECLS-K

ECLS-K

ECLS-K:2011
To what extent is each of the following matters a problem in this school? Indicate whether 

each is a SERIOUS problem, a MODERATE problem, a MINOR problem, or NOT a problem in 

this school.

a. Student tardiness

b. Student absenteeism

c. Student aggressive or disruptive behavior

d. Teacher absenteeism

e. Teacher turnover

f. Overcrowding

During the past year, to what extent did any of the following changes occur at your school?

a. Funding levels decreased

b. Enrollment increased

c. Enrollment decreased

d. The number of students receiving free or reduced-price lunch increased

e. Student mobility increased (that is, the number of students transferring in and out of 

the school increased)

f. There has been a reduction in staffing

g. Class sizes increased

h. Class sizes decreased

i. Salaries increased

j. Salaries decreased

k. Number of English language learners increased

During the past year, were salaries frozen at your school? ECLS-K:2011 

Grade 1

IF YOUR SCHOOL IS A PRIVATE, MAGNET, OR CHARTER SCHOOL, SKIP TO C1. IF YOUR 

SCHOOL IS NOT A PRIVATE, MAGNET OR CHARTER SCHOOL, GO TO Q B12.

During the past year, were changes made to your school's assigned attendance area? ECLS-K:2011 

Grade 1

How many third-grade children were retained at their current grade level last school year? ECLS-K

How many fourth-grade children were retained at their current grade level last school year? ECLS-K

Is a school-wide positive behavioral intervention and support program (for example, 

Positive Behavioral Support, Positive Behavioral Intervention System) implemented at your 

school?

Adapted from 

FRSS 99 

Dropout 

Prevention 

Services and 

Programs 

survey

For each of the following statements about READING and MATH, indicate how strongly you 

agree or disagree.

For READING

a. This school has a set of clear, predetermined, grade-level benchmarks (that is, cut 

scores, goals/targets, or percentiles) that are used to determine which students are 

struggling or at risk of failure in READING.

ECLS-K

ECLS-K

Adapted from 

WA (RTI) and 

HB 2136: 

Spring 2010
b. At this school, we use data from screening tests to determine if core instruction in 

READING is meeting the needs of most of our students.

For MATH

c. This school has a set of clear, predetermined, grade-level benchmarks (that is, cut 

scores, goals/targets, or percentiles) that are used to determine which students are 

struggling or at risk of failure in MATH.

d. At this school, we use data from screening tests to determine if core instruction in 

MATH is meeting the needs of most of our students.

Is Response to Intervention (RtI) currently used at your school in fourth grade, either 

partially or fully implemented? RESPONSE TO INTERVENTION (RTI) IS A MULTI-STEP 

APPROACH TO PROVIDING EARLY AND PROGRESSIVELY INTENSIVE INTERVENTION AND 

MONITORING WITHIN THE GENERAL EDUCATION SETTING.

Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)

Is RtI currently implemented at your school in fourth grade in the following areas?

a. Math

b. Reading

c. Writing

d. Behavior/Social skills

Approximately how many years ago did your school begin implemementing RtI in fourth 

grade in any subject? Less than 1 year ago; 1 to 2 years ago; More than 2 years ago

ECLS-K:2011 

Grade 1

For the 2014-2015 school year, how has your school made information available to 

parents/guardians to help them understand how RtI is being implemented in your school?

a. Communication through written materials such as letters, email, school website, or 

newsletters

b. Communication through workshops, discussion groups, or other meetings such as PTA 

meetings

c. Communication through individual meetings with parents or phone calls

d. Information is not distributed on this topic

Has your school implemented the Common Core State Standars at any grade(s)? ECLS-K:2011

Are the Common Core State Standares currently implemented at your school in fourth 

grade in the following areas?

a. Reading and Language Arts

b. Mathematics

Approximately how many years ago did your school begin implementing the Common Core 

State Standards in any grade or subject? Less than 1 year ago; 1 to 2 years ago; More 

than2 years ago

ECLS-K:2011

Do any of the children in this school come from a home where a language other than 

English is spoken?

ECLS-K

ECLS-K:2011

Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)

Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)
What percentage of children in this school are English language learners (ELL)? ECLS-K

What percentage of children in fourth grade are English language learners (ELL)? ECLS-K

Are any of the following services provided to families of children from households where a 

language other than English is spoken? 

a. Translators are made available to parents for parent/teacher and parent/school staff 

meetings and/or meetings are conducted in the parents' non-English language.

b. Translations of written communications are provided to these parents.

c. Home visits are made to families of these children.

Since the beginning of this school year (2014-2015), how many students have been NEWLY 

evaluated at your school to determine if they are eligible for an IEP?

Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)

Of those students who have been NEWLY evaluated at your school this school year (2014-

2015), how many were found eligible for an IEP, including those who may have an IEP for 

speech only?

Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)

What method(s) are used in your school to determine special education ELIGIBILITY for 

students with learning disabilities? IF A COMBINATION OF THESE METHODS IS USED AT 

YOUR SCHOOL, MARK YES FOR BOTH A AND B. RESPONSE TO INTERVENTION (RTI) IS A 

MULTI-STEP APPROACH TO PROVIDING EARLY AND PROGRESSIVELY INTENSIVE 

INTERVENTION AND MONITORING WITHIN THE GENERAL EDUCATION SETTING.

a. IQ-achievement discrepancy model which shows whether there is a discrepancy 

between expected performance and actual performance

b. Response to Intervention (RtI) model

Approximately what percentage of your fourth-graders are in each of the following 

instructional programs? WRITE PERCENTAGES IN BOXES. IF NONE, WRITE "0" AND 

INDICATE IF THE PROGRAM IS NOT OFFERED IN FOURTH GRADE OR IN ANY GRADE IN 

a. Special education with an Individualized Education Program (IEP)

b. Receive accommodations through a 504 plan

c. Reading instruction for students performing below grade level in reading

ECLS-K

Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)

ECLS-K
d. Math instruction for students performing below grade level in math

e. A gifted and talented program

Where are children with Individualized Education Programs (IEPs) typically served in this 

school? Children with IEPs are not served in this school; Children with IEPs typically spend 

most of their day in separate classes; Children with IEPs typically spend most of their day in 

the regular classroom

ECLS-K

The following items pertain to public schools only. IF YOURS IS A PRIVATE SCHOOL CHECK 

HERE.

ECLS-K:2011

Did your school receive Federal Title I funds for this school year? ECLS-K:2011

Is your school operating a Title I targeted assistance or schoolwide program? Targeted 

assistance program; Schoolwide program

ECLS-K:2011

Did your school receive Federal Title III funds for this school year? (Title III is “Language 

Instruction for Limited English Proficient and Immigrant Students.”)

ECLS-K:2011

At the end of the LAST school year (2013-2014), did this school make Adequate Yearly 

Progress (AYP)? (Adequate Yearly Progress is your state’s measure of yearly progress 

toward achieving state academic standards.)

ECLS-K:2011, 

based on 

NCLB Title I 

regulations 

At the end of the LAST school year (2013-2014), was this school identified for improvement 

due to Adequate Yearly Progress (AYP) requirements? (A school is identified for 

improvement if it does not make Adequate Yearly Progress for two consecutive years or 

more in the same

content area.)

ECLS-K:2011, 

based on 

NCLB Title I 

regulations 

Approximately how many staff members does your school currently have in the following 

categories? PLEASE PROVIDE RESPONSES IN COLUMN (1) FOR STAFF MEMBERS WHO 

WORK FULL TIME AT YOUR SCHOOL AND IN COLUMN (2) FOR STAFF WHO WORK PART 

TIME AT YOUR SCHOOL. IF A STAFF MEMBER IS SHARED WITH OTHER SCHOOLS, COUNT 

THAT PERSON AS "PART TIME" IN YOUR SCHOOL. PLACE EACH STAFF MEMBER IN ONLY 

ONE STAFF CATEGORY; IF A STAFF MEMBER FITS MORE THAN ONE CATEGORY, PICK THE 

CATEGORY MOST DESCRIPTIVE OF HIS/HER WORK.

a. Regular classroom teachers

b. ESL/bilingual education/language immersion/ELL instruction teachers

c. Drama, music, or art teachers

d. Gym/PE or health teachers

e. Special education teachers and related service providers (for example, speech therapist, 

physical therapist, adaptive physical education, etc.)

f. Paraprofessionals (for example, classroom aides)

Does your school currently have any staff members (full- or part-time) in the following 

categories? INCLUDE THOSE WHO ARE FULL- OR PART-TIME STAFF MEMBERS AT YOUR 

SCHOOL.

a. Teachers of gifted/talented students

ECLS-K:2011, 

Grade 1

ECLS-K
b. Reading specialists and interventionists

c. Math specialists and interventionists

d. School nurses or health professionals

e. School psychologists or social workers

f. Guidance counselors

g. Library media specialists/librarians

h. Computer/technology teachers or support staff

Does your school currently have any staff members who do the following as their primary 

role or one of their primary roles? INCLUDE THOSE WHO ARE FULL- OR PART-TIME STAFF 

MEMBERS AT YOUR SCHOOL.

ECLS-K

a. A school staff member who provides ongoing training or support to classroom teachers 

in the delivery of effective READING instruction

b. A school staff member who provides ongoing training or support to classroom teachers 

in the delivery of effective MATH instruction

c. A school staff member who provides ongoing training or support to classroom teachers 

in the delivery of effective behavioral supports

d. A school staff member who supports teachers in collecting, organizing, and managing 

assessment data

e. A school staff member who supports teachers in the interpretation and use of 

assessment data to guide instruction

Please indicate the number of regular classroom teachers who have joined or left your 

school since October 1, 2014.

a. Number of regular classroom teachers who have begun teaching in your school since 

October 1, 2014

b. Number of regular classroom teachers who have left your school since October 1, 2014

Are monetary incentives such as cash bonuses, salary increases, or different steps on the 

salary schedule used in your school to reward teachers for... 

a. Improved student performance on state tests?

b. Reaching target goals on state tests?

Did this school's principal (or head administrator) complete the majority of the previous 

sections or was the majority completed by someone else?

ECLS-K

If a person other than the school's principal (or head administrator) has completed the 

previous sections, please write in the name and title of the person who completed the 

majority of the sections.

ECLS-K

How long has the individual listed above been employed at this school? ECLS-K

What is your gender? ECLS-K

In what year were you born? ECLS-K

ECLS-K:2011, 

Grade 1

ECLS-K
Are you Hispanic or Latino? ECLS-K

Which best describes your race? MARK ONE OR MORE RESPONSES TO INDICATE WHAT 

YOU CONSIDER YOURSELF TO BE. American Indian or Alaska Native; Asian; Black or African 

American; Native Hawaiian or Other Pacific Islander; White

ECLS-K

How many years of experience do you have in each of the following positions, including 

years in which you worked part time? 

a. Years as a teacher before becoming a school administrator

b. Total numbers of years as a school administrator

c. Number of years as school administrator at this school

Through which, if any, of the types of training programs below did you receive preparation 

for fulfilling your role as a school administrator?

a. Traditional university-based training and certification program

b. District-based training program (for example, the Boston Principal Fellowship, New York 

City Leadership Academy's Aspiring Principals Program, Chicago's LAUNCH program)

c. City-based training program (for example, Cleveland's First Ring Leadership Academy )

d. State-based training program (for example, New Jersey EXCEL)

e. Training and/or certification program run by a national non- profit organization (for 

example, KIPP School Leadership Program, New Leaders for New Schools)

f. Another school administration preparation program

What is the highest level of education you have completed? High school diploma or 

equivalent/GED; Associate's degree; Bachelor's degree; At least one year of coursework 

beyond a Bachelor's degree but not a graduate degree; Master's degree; Education 

specialist or professional diploma based on at least one year of coursework past a Master's 

degree level; Doctorate or an advanced professional degree beyond a Master's degree (for 

example, MD, EdD)

ECLS-K

What was your major field(s) of study in the highest degree you completed?

a. Early childhood education

b. Elementarty education

c. Education administration/management

d. Special education

e. Other education-related major (such as secondary education, educational psychology, 

science education, music education, etc.)

f. Non-education major (such as history, English, etc.)

What is your best estimate of the percentage of children in your school you know by 

name? Nearly every child; 75% or more; 51% to 75%; 26% to 50%; 25% or less

ECLS-K

During school hours, do you speak a language other than English with students at your 

school whose native language is not English?

ECLS-K

ECLS-K

ECLS-K

ECLS-K:2011, 

Grade K
Do you speak a language other than English with students’ families whose native language 

is not English?

ECLS-K

If you do not speak a language other than English with EITHER students OR students’ 

families whose native language is not English, mark here and SKIP TO Q G14. 

ECLS-K

What language(s) other than English do you speak with students at your school or with 

their families? Spanish; Vietnamese; A Chinese language; Japanese; Korean; A Filipino 

language; Arabic; Other (PLEASE SPECIFY)

ECLS-K

Date questionnaire completed/Questionnaire completed by: ECLS-K
Construct

Research 

Question

Length of school year SAQ1

Enrollment and 

attendance

SAQ7

School type (grade levels) SAQ2

N/A N/A

School type 

(public/private/affiliation; 

grades; magnet; etc)

SAQ2

School type 

(public/private/affiliation; 

grades; magnet; etc)

SAQ2

Enrollment and 

attendance

SAQ2

School type 

(public/private/affiliation; 

grades; magnet; etc)

SAQ2
School type 

(public/private/affiliation; 

grades; magnet; etc)

SAQ2

Student demographic 

information: indicator of 

poverty

SAQ2

School-based programs 

or services for parents 

and families

SAQ3, SAQ4

Parent outreach and 

communication

SAQ3, SAQ4

Student demographic 

information: transfers 

from outside attendance 

area

SAQ2

Student demographic 

information: 

race/ethnicity distribution

SAQ2
Parent outreach and 

communication

SAQ3, SAQ4

Parent outreach and 

communication

SAQ3, SAQ4

School safety SAQ7

Neighborhood problems SAQ6

Measures taken to 

ensure school safety

SAQ7

Parent outreach and 

communication

SAQ3, SAQ4
Recent changes at the 

school

SAQ2

Recent changes at the 

school

SAQ2

Retention policies and 

practices

SAQ2

Retention policies and 

practices

SAQ2

Response to Interventionrelated policies and 

practices

SAQ9

Recent changes at the 

school

SAQ2

Enrollment and 

attendance; School 

climate; Teacher mobility

Response to Interventionrelated policies and 

practices

SAQ9

SAQ7
Response to Interventionrelated policies and 

practices

SAQ9

Response to Interventionrelated policies and 

practices

SAQ9

Implementation of 

Common Core State 

Standards

SAQ10

Implementation of 

Common Core State 

Standards

SAQ10

Student demographic 

information: language 

other than English

SAQ2

Implementation of 

Common Core State 

Standards

SAQ10

Response to Interventionrelated policies and 

practices; parent 

outreach and 

communication

SAQ9, SAQ3

Response to Interventionrelated policies and 

practices

SAQ9
Delivery of instruction to 

English Language 

Learners (ELL) and 

services for language 

minority (LM) families

SAQ2

Delivery of instruction to 

English Language 

Learners (ELL) and 

services for language 

minority (LM) families

SAQ2

Evaluation for IEP SAQ9

Special education 

eligibility

SAQ9

Delivery of special 

education and related 

services to children with 

disabilities

SAQ4

Special education 

eligibility

SAQ9

Delivery of instruction to 

English Language 

Learners (ELL) and 

services for language 

minority (LM) families

SAQ5
Delivery of special 

education and related 

services to children with 

disabilities

SAQ4

N/A NA

Services and programs: 

Title I

SAQ2

Services and programs: 

Title I

SAQ2

Services and programs: 

Title III

SAQ2

School status relative to 

Adequate Yearly Progress 

(AYP)

SAQ2

School status relative to 

Adequate Yearly Progress 

(AYP) and school 

improvement

SAQ2

Number of staff members 

and specialists

SAQ2

Numbers of full- and parttime teachers, specialists, 

nurses, and 

paraprofessionals

SAQ2
Response to Interventionrelated policies and 

practices

SAQ9

N/A N/A

N/A N/A

School administrator 

demographic information

SAQ8

School administrator 

demographic information

SAQ8

School administrator 

demographic information

SAQ8

Teacher mobility SAQ2; SAQ7

Teacher Incentives SAQ2
School administrator 

demographic information

SAQ8

School administrator's 

experience 

SAQ8

School administrator's 

formal education and 

training

SAQ8

School administrator’s 

use of a non-English 

language

SAQ8

School administrator’s 

use of a non-English 

language

SAQ8

School administrator’s 

familiarity with students

SAQ8

School administrator's 

formal education and 

training

SAQ8

School administrator's 

formal education and 

training

SAQ8
School administrator’s 

use of a non-English 

language

SAQ8

School administrator’s 

use of a non-English 

language

SAQ8

School administrator’s 

familiarity with students

SAQ8
Section Item #

School Characteristics A1

A3

A4

B3

B4

B2 a-b

School-Family-Community 

Connections

B1 a-f

Spring Fourth-Grade School Administrator Questionnaire For Continuing Schools, Appendix H

A2 a-d
B9 a-k

B8 a-f

B7a-g

B5 a-b

B6 a-i
B10

B11

School Policies and Practices C1

C2

C3

C5

C6 a-d

C4 a-d
C7

C9

C11

School Programs for 

Particular Populations

D1

D2

D3

C10 ab

C8 a-d
D4

D5

Federal Programs: Title I and 

Title III

E1

E2

E3

D7 a-e

D6 a-b
F3 a-e

F2 a-h

Staffing and Teacher 

Characteristics

F1 a-f
F6

F7

F8

School Administrator 

Characteristics

G1

G2

G3

G4

G6 a-f

G5 a-c

F5 a-b

F4 a-b
G7

G8 a-f

G9

G10
Item Stem Source

How many instructional days will this school provide during this academic year? IF THIS 

IS A YEAR-ROUND SCHOOL, PLEASE PROVIDE THE NUMBER OF INSTRUCTIONAL DAYS A 

GIVEN CHILD WOULD ATTEND.

ECLS-K

School enrollment. WRITE IN THE APPROXIMATE NUMBER OF CHILDREN FOR EACH OF 

THE FOLLOWING.

a. Total enrollment in fourth grade in your school around October 1, 2014, or the date 

nearest to that for which data are available

b. Total enrollment for your school (across all grades) around October 1, 2014, or the 

date nearest to that for which data are available

c. Number of children who have enrolled in your school Sicne October 1, 2014

d. Number of children who have left your school since October 1, 2014, and have not 

returned

Approximately what is the Average Daily Attendance for your school this year? WRITE IN 

PERCENT OR NUMBER BELOW. TO CALCULATE PERCENT, DIVIDE THE NUMBER OF 

STUDENTS ATTENDING ON AN AVERAGE DAY BY THE NUMBER OF STUDENTS ENROLLED 

AND THEN MULTIPLY BY 100.

ECLS-K

About what percentage of the children enrolled in this school are eligible for free or 

reduced-price lunch?

ECLS-K 

Please indicate how often each of the following activities is provided by your school. 

a. PTA, PTO, or Parent-Teacher-Student organization meetings

b. Reports (report cards) of chldren's performance provided to parents

c. Information on the child's standardized assessment scores provided to parents

d. Teacher-parent conferences

e. School performances to which parents are invited

f. Classroom programs like class plays, book nights, or family math nights

During this school year, how often has your school used the following ways to 

communicate with all parents?

a. Electronic communication to all parents, such as group emails, electronic newsletters, 

website postings, "robocalls" (mass automated phone calls), text alerts, or other 

electronic notices for all parents

b. Non-electronic communications to all parents, such as letters, newsletters, phone 

calls, or other non-electronic messages for all parents

During this school year, has your school used an online tool or website that is available to 

the general public and that parents can access without a login or password?

ECLS-K:2011

During this school year, has your school (or individual teachers) used an online tool or 

website that parents can only access with a login or password to get information about 

their child, the child's class, or the school?

ECLS-K:2011

ECLS-K:2011

ECLS-K

 School Administrator Questionnaire For Continuing Schools, Appendix H

ECLS-K
Have the following types of information been provided in the online tool or website that 

parents can only access with a login and password?

a. Classroom-specific assignments, including homework

b. Child- or parent-specific information, such as progress reports between grading periods

To the best of your knowledge how often do the following types of problems occur at 

your school?

a. Children bringing weapons to school

b. Theft

c. Physical conflicts among students

d. Children bringing in or using alcohol at school

e. Children bringing in or using illegal drugs at school

f. Vandalism of school property

g. Student bullying

h. Widespread disorder in classrooms

i. Class cutting

Does your school take any of the following measures to ensure the safety of children?

a. Security guards, unarmed

b. Security guards, armed

c. Metal detectors

d. Locked doors during the school day

e. A requirement that visitors sign in

f. Intercoms or telephones in classrooms

g. Other (PLEASE SPECIFY)

To what extent is each of the following matters a problem in this school? Indicate 

whether each is a SERIOUS problem, a MODERATE problem, a MINOR problem, or NOT a 

problem in this school.

a. Student tardiness

b. Student absenteeism

c. Student aggressive or disruptive behavior

d. Teacher absenteeism

e. Teacher turnover

f. Overcrowding

During the past year, to what extent did any of the following changes occur at your 

school?

a. Funding levels decreased

b. The number of students receiving free or reduced-price lunch increased

c. There has been a reduction in staffing

d. Class sizes increased

e. Class sizes decreased

f. Salaries increased

g. Salaries decreased

During the past year, were salaries frozen at your school?

ECLS-K

ECLS-K

ECLS-K

ECLS-K:2011

ECLS-K
IF YOUR SCHOOL IS A PRIVATE, MAGNET, OR CHARTER SCHOOL, SKIP TO Q C1. IF YOUR 

SCHOOL IS NOT A PRIVATE, MAGNET, OR CHARTER SCHOOL, GO TO Q B11.

During the past year, were changes made to your school's assigned attendance area?

How many third-grade children were retained at their current grade level last school year?

How many fourth-grade children were retained at their current grade level last school 

year?

ECLS-K:2011 

Grade 1

Is a school-wide positive behavioral intervention and support program (for example, 

Positive Behavioral Support, Positive Behavioral Intervention System) implemented at 

your school?

For each of the following statements about READING and MATH, indicate how strongly 

you agree or disagree.

ECLS-K:2011 

Grade 1

For READING ECLS-K

a. This school has a set of clear, predetermined, grade-level benchmarks (that is, cut 

scores, goals/targets, or percentiles) that are used to determine which students are 

struggling or at risk of failure in READING.

ECLS-K

b. At this school, we use data from screening tests to determine if core instruction in 

READING is meeting the needs of most of our students.

Adapted from 

FRSS 99 

Dropout 

Prevention 

For MATH

c. This school has a set of clear, predetermined, grade-level benchmarks (that is, cut 

scores, goals/targets, or percentiles) that are used to determine which students are 

struggling or at risk of failure in MATH.

d. At this school, we use data from screening tests to determine if core instruction in 

MATH is meeting the needs of most of our students.

Is Response to Intervention (RtI) currently used at your school in fourth grade, either 

partially or fully implemented? RESPONSE TO INTERVENTION (RTI) IS A MULTI-STEP 

APPROACH TO PROVIDING EARLY AND PROGRESSIVELY INTENSIVE INTERVENTION AND 

MONITORING WITHIN THE GENERAL EDUCATION SETTING.

Is RtI currently implemented at your school in fourth grade in the following areas?

a. Math

b. Reading

c. Writing Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)

d. Behavior/Social skills Adapted from 

IDEA national 

Adapted from 

WA (RTI) and 

HB 2136: 

Spring 2010
Approximately how many years ago did your school begin implemementing RtI in fourth 

grade in any subject? Less than 1 year ago; 1 to 2 years ago; More than 2 years ago

For the 2014-2015 school year, how has your school made information available to 

parents/guardians to help them understand how RtI is being implemented in your school?

a. Communication through written materials such as letters, email, school website, or 

newsletters

b. Communication through workshops, discussion groups, or other meetings such as PTA 

meetings

c. Communication through individual meetings with parents or phone calls New

d. Information is not distributed on this topic

Has your school implemented the Common Core State Standars at any grade(s)?

Are the Common Core State Standares currently implemented at your school in fourth 

grade in the following areas?

a. Reading and Language Arts

b. Mathematics

Approximately how many years ago did your school begin implementing the Common 

Core State Standards in any grade or subject? Less than 1 year ago; 1 to 2 years ago; 

More than 2 years ago

New

Do any of the children in this school come from a home where a language other than 

English is spoken?

What percentage of children in this school are English language learners (ELL)?

What percentage of children in fourth grade are English language learners (ELL)?

Since the beginning of this school year (2014-2015), how many students have been 

NEWLY evaluated at your school to determine if they are eligible for an IEP?

New

Of those students who have been NEWLY evaluated at your school this school year (2014-

2015), how many were found eligible for an IEP, including those who may have an IEP for 

speech only?

ECLS-K

What method(s) are used in your school to determine special education ELIGIBILITY for 

students with learning disabilities? IF A COMBINATION OF THESE METHODS IS USED AT 

YOUR SCHOOL, MARK YES FOR BOTH A AND B. RESPONSE TO INTERVENTION (RTI) IS A 

MULTI-STEP APPROACH TO PROVIDING EARLY AND PROGRESSIVELY INTENSIVE 

INTERVENTION AND MONITORING WITHIN THE GENERAL EDUCATION SETTING.

ECLS-K

a. IQ-achievement discrepancy model which shows whether there is a discrepancy 

between expected performance and actual performance

ECLS-K

New

Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)

IDEA national 

Assessment 

Implementatio

n Study (LEA)
b. Response to Intervention (RtI) model Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)

Approximately what percentage of your fourth-graders are in each of the following 

instructional programs? WRITE PERCENTAGES IN BOXES. IF NONE, WRITE "0" AND 

INDICATE IF THE PROGRAM IS NOT OFFERED IN FOURTH GRADE OR IN ANY GRADE IN 

YOUR SCHOOL.

Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)

a. Special education with an Individualized Education Program (IEP)

b. Receive accommodations through a 504 plan

c. Reading instruction for students performing below grade level in reading

d. Math instruction for students performing below grade level in math ECLS-K

e. A gifted and talented program

The following items pertain to public schools only. IF YOURS IS A PRIVATE SCHOOL CHECK 

HERE.

Did your school receive Federal Title I funds for this school year? 

Is your school operating a Title I targeted assistance or schoolwide program? Targeted 

assistance program; Schoolwide program

Did your school receive Federal Title III funds for this school year? (Title III is “Language 

Instruction for Limited English Proficient and Immigrant Students.”)

Approximately how many staff members does your school currently have in the following 

categories? PLEASE PROVIDE RESPONSES IN COLUMN (1) FOR STAFF MEMBERS WHO 

WORK FULL TIME AT YOUR SCHOOL AND IN COLUMN (2) FOR STAFF WHO WORK PART 

TIME AT YOUR SCHOOL. IF A STAFF MEMBER IS SHARED WITH OTHER SCHOOLS, COUNT 

THAT PERSON AS "PART TIME" IN YOUR SCHOOL. PLACE EACH STAFF MEMBER IN ONLY 

ONE STAFF CATEGORY; IF A STAFF MEMBER FITS MORE THAN ONE CATEGORY, PICK THE 

CATEGORY MOST DESCRIPTIVE OF HIS/HER WORK.

a. Regular classroom teachers ECLS-K

b. ESL/bilingual education/language immersion/ELL instruction teachers ECLS-K

c. Drama, music, or art teachers ECLS-K

Adapted from 

IDEA national 

Assessment 

Implementatio

n Study (LEA)
d. Gym/PE or health teachers

e. Special education teachers and related service providers (for example, speech 

therapist, physical therapist, adaptive physical education, etc.)

f. Paraprofessionals (for example, classroom aides)

Does your school currently have any staff members (full- or part-time) in the following 

categories? INCLUDE THOSE WHO ARE FULL- OR PART-TIME STAFF MEMBERS AT YOUR 

SCHOOL.

a. Teachers of gifted/talented students

b. Reading specialists and interventionists

c. Math specialists and interventionists

d. School nurses or health professionals

e. School psychologists or social workers

f. Guidance counselors

g. Library media specialists/librarians

h. Computer/technology teachers or support staff

Does your school currently have any staff members who do the following as their primary 

role or one of their primary roles? INCLUDE THOSE WHO ARE FULL- OR PART-TIME STAFF 

MEMBERS AT YOUR SCHOOL.

a. A school staff member who provides ongoing training or support to classroom teachers 

in the delivery of effective READING instruction

b. A school staff member who provides ongoing training or support to classroom 

teachers in the delivery of effective MATH instruction

c. A school staff member who provides ongoing training or support to classroom teachers 

in the delivery of effective behavioral supports

d. A school staff member who supports teachers in collecting, organizing, and managing 

assessment data

e. A school staff member who supports teachers in the interpretation and use of 

assessment data to guide instruction

Please indicate the number of regular classroom teachers who have joined or left your 

school since October 1, 2014.

a. Number of regular classroom teachers who have begun teaching in your school since 

October 1, 2014

b. Number of regular classroom teachers who have left your school since October 1, 

2014, and have not reurned

Are monetary incentives such as cash bonuses, salary increases, or different steps on the 

salary schedule used in your school to reward teachers for... 

New

ECLS-K

ECLS-K
a. Improved student performance on state tests?

b. Reaching target goals on state tests?

Did this school's principal (or head administrator) complete the majority of the previous 

sections or was the majority completed by someone else?

If a person other than the school's principal (or head administrator) has completed the 

previous sections, please write in the name and title of the person who completed the 

majority of the sections. How long has the individual listed above been employed at this school?

What is your gender?

In what year were you born? ECLS-K

Are you Hispanic or Latino? ECLS-K

Which best describes your race? MARK ONE OR MORE RESPONSES TO INDICATE WHAT 

YOU CONSIDER YOURSELF TO BE. American Indian or Alaska Native; Asian; Black or 

African American; Native Hawaiian or Other Pacific Islander; White

ECLS-K

How many years of experience do you have in each of the following positions, including 

years in which you worked part-time? 

ECLS-K

a. Years as a teacher before becoming a school administrator ECLS-K

b. Total numbers of years as a school administrator ECLS-K

c. Number of years as school administrator at this school ECLS-K

Through which, if any, of the types of training programs below did you receive 

preparation for fulfilling your role as a school administrator?

a. Traditional university-based training and certification program

b. District-based training program (for example, the Boston Principal Fellowship, New 

York City Leadership Academy's Aspiring Principals Program, Chicago's LAUNCH program)

c. City-based training program (for example, Cleveland's First Ring Leadership Academy )

d. State-based training program (for example, New Jersey EXCEL)

e. Training and/or certification program run by a national non- profit organization (for 

example, KIPP School Leadership Program, New Leaders for New Schools)

f. Another school administration preparation program

ECLS-K:2011, 

Grade K

ECLS-K

ECLS-K

ECLS-K
What is the highest level of education you have completed? High school diploma or 

equivalent/GED; Associate's degree; Bachelor's degree; At least one year of coursework 

beyond a Bachelor's degree but not a graduate degree; Master's degree; Education 

specialist or professional diploma based on at least one year of coursework past a 

Master's degree level; Doctorate or an advanced professional degree beyond a Master's 

degree (for example, MD, EdD)

What was your major field(s) of study in the highest degree you completed?

a. Early childhood education

b. Elementarty education

c. Education administration/management ECLS-K

d. Special education

e. Other education-related major (such as secondary education, educational psychology, 

f. Non-education major (such as history, English, etc.)

What is your best estimate of the percentage of children in your school you know by 

name? Nearly every child; 75% or more; 51% to 75%; 26% to 50%; 25% or less

During school hours, do you speak a language other than English with students at your 

school whose native language is not English?

Do you speak a language other than English with students’ families whose native language 

is not English?

If you do not speak a language other than English with EITHER students OR students’ 

families whose native language is not English, mark here and SKIP TO Q G14.

What language(s) other than English do you speak with students at your school or with 

their families? Spanish; Vietnamese; A Chinese language; Japanese; Korean; A Filipino 

language; Arabic; Other (PLEASE SPECIFY)

ECLS-K

Date questionnaire completed/Questionnaire completed by: ECLS-K

ECLS-K
Construct

Research 

Question

Length of school year SAQ1

Enrollment and attendance SAQ7

Student demographic 

information: indicator of 

poverty

SAQ2

Parent outreach and 

communication

SAQ3, SAQ4

Parent outreach and 

communication

SAQ3, SAQ4

Parent outreach and 

communication

SAQ3, SAQ4

School-based programs or 

services for parents and 

families

SAQ3

Enrollment and attendance SAQ2
SAQ3, SAQ4

Recent changes at the 

school

SAQ2

Enrollment and 

attendance; School 

climate; Teacher mobility

SAQ7

SAQ7

Measures taken to ensure 

school safety

SAQ7

Parent outreach and 

communication

School safety
Recent changes at the 

school

SAQ2

N/A N/A

Recent changes at the 

school

SAQ2

Retention policies and 

practices

SAQ2

Retention policies and 

practices

SAQ2

Response to Interventionrelated policies and 

practices

SAQ9

Response to Interventionrelated policies and 

practices

SAQ9

Response to Interventionrelated policies and SAQ9

Response to Interventionrelated policies and 

practices

SAQ9
Response to Interventionrelated policies and 

practices

SAQ9

Implementation of 

Common Core State 

Standards

SAQ10

Implementation of 

Common Core State 

Standards

SAQ10

Student demographic 

information: language 

other than English

SAQ2

Delivery of instruction to 

English Language Learners 

(ELL) and services for 

language minority (LM) 

families

SAQ2

Delivery of instruction to 

English Language Learners 

(ELL) and services for 

language minority (LM) 

families

SAQ2

Implementation of 

Common Core State 

Standards

SAQ10

Response to Interventionrelated policies and 

practices; parent outreach 

and communication

SAQ9, SAQ3

related policies and 

practices
Evaluation for IEP SAQ9

Special education eligibility SAQ9

N/A N/A

Services and programs: 

Title I

SAQ2

Services and programs: 

Title I

SAQ4

Services and programs: 

Title III

SAQ2

Delivery of special 

education and related 

services to children with 

disabilities

SAQ4

Special education eligibility SAQ9
Response to Interventionrelated policies and 

practices

SAQ9

Numbers of full- and parttime teachers, specialists, 

nurses, and 

paraprofessionals

SAQ2

Total number of full- and 

part-time teachers, 

specialists, nurses, and 

paraprofessionals

SAQ2
N/A N/A

N/A N/A

N/A N/A

School administrator 

demographic information

SAQ8

School administrator 

demographic information

SAQ8

School administrator 

demographic information

SAQ8

School administrator 

demographic information

SAQ8

School administrator's 

formal education and 

training

SAQ8

School administrator's 

experience 

SAQ8

Teacher Incentives SAQ2

Teacher mobility SAQ2; SAQ7
School administrator's 

formal education and 

training

SAQ8

School administrator’s 

familiarity with students

SAQ8

School administrator's 

formal education and 

training

SAQ8