Prepared by Mathematica Policy Research

OMB No. XXXXX-xxx Expiration Date: xx/xx/20xx 

# IMPACT EVALUATION OF SUPPORT

**FOR PRINCIPALS PRINCIP** **A L**  **SURVEY**

XXX , 2015 This questionnaire is part of the Im pact Evaluation of Support for Principals, a national evaluation being conducted for the U.S. Department of Education by Mathematica Policy research. The questionnaire asks about the professional development and supports you received in the 2015-2016 school year, yo ur school’s climate and culture, and your teaching background and experience
. **We want you to know that:** 1. This survey

is voluntary, but yo ur response is critical for producing valid and reliable data. Yo u may skip any questions you do not wish to answer; however, we hope that you answer as many questions as you can. Yo ur answers to questions will not affect yo ur job or any h iring decisions now or in the future and will only be shared with the Mathematica study team(they will not be shared with anyone from yo ur school or district)
. Participation in the principal survey will not im pose any risks to you as a respondent. If you have any questions about your rights as a research volunteer, contact XXX at New England I RB, toll free XXX-XXX-XXXX
. 2. The U.S. Department of Education is committed to protecting the privacy of individuals who participate in surveys. All information you provide will be kept strictly confidential and used for research purposes only. Your answers will be combined with other surveys, and no information identifyi ng individual teachers or their schools will be released. Thank you for your help with this survey. This evaluation is authorized by Title IX, Part F of the Elementary and Secondary Education Act, section 9601 as amended by the “No Child Left Behind Act of 2001” (20 USC 7941) as it relates to Title II, Part A of the Elementary and Secondary Education Act (ESEA), section 2121 -2123 as amended by No Child Left Behind (NCLB) (20 USC 6621 -6623) . According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is **XXXXX -** **XXX**
. The time required to complete this information collection is estimated to average 30 minutes per respondent, including the time to review i nstructions, gather the data needed, and complete and review the information collected. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U .S. Department of Education, Washington, DC 20202. If you have comme nts or concerns regarding the status of your individual submission of this form, write directly to: U .S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW,Washington, DC 20208.Prepared by Mathematica Policy Research 2 **SECTION A .**  **YOUR PRINCIPA** **L PROFESSIONA L DEVELOPMENT & SUPPORT**  T his section includes questions about the professional development and supports that you received in the past year. First, please tell us about the different types of professional development and supports that you received. **A1. P**  **lease estimate**  **the total number of hours**  **and usefulness of the following**  **typ es of**  **professional development and**  **supports that**  **you received between June 1, 2015 and today** **. In Column A** **: For each type,**  **in dicate the total number of hours.**  **If you did not participate** 

**in this**  **area, enter**  **“ 0.”**  **In Column B:**  **For each type, mark the usefulness. If you did not**  **participate in this area,** 

**mark “N/A .”**   Between June 1, 2015 and today, I did not receive any the following
................. 0 **GO TO A4** 

A. Total Hours of Support B. Usefulness of support? Not Very Useful Somewhat

Useful Moderately

Useful Very

Useful N/A a. Formal degree program or university courses (online or in person) 1  2  3  4  n  b. Formal group learning sessions , such as workshops, conferences, or seminars 1  2  3  4  n  c. One-on-one development opportunities such as leadership mentoring or coaching 1  2  3  4  n  d. Other development opportunities, such as observing classrooms for training purposes as a group , participating in professional development for teachers , or participating in a professional learning community 1  2  3  4  n Prepared by Mathematica Policy Research 3

**A 2**  **. Thinking about all the supports that you just reported receiving**  **between June 1, 2015 and today ,**  **please estimate**  **the percentage of time those supports targeted each of the following content areas (for example, roughly**  **5% of**  **time was**  **spent on c ontent in**  **A, 60%**  **on content in**  **B , 35% on**  **content in C**  **, and 0% on other areas).** Percentage of Target Support a. Recruiting, interviewing, hiring, dismissing or promoting staff, assigning teachers to grades and students , designing professional development activities for staff, and other content related to managing your school staff b. Observing classroom instruction , providing feedback to teachers on their instructional practice , taking steps to align curriculum, assessments, or standards , and other content related to supporting instructional practice in your school c. Planning school improvements, setting and communicating school improvement goals , communicating prog ress towards school improvement, community/parent outreach, student affairs , and other content related to operations, finances, and administration of your school d. Professional development or supports in any other area (specify) TOTALPrepared by Mathematica Policy Research 4

Now that you’ve told us about the types of supports you received, please tell us about your perceptions of those supports
. **A 3**  **. Thinking broadly about all the supports that you received**  **between June 1, 2015 and today** **, indicate the**  **extent to which you agree**  **or disagree with**  **the following statements about that support**  **: The support** **s I received...**  IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a. were aligned with my own improvement goals 1  2  3  4  b
. were consistent with school-wide goals or plans for improvement 1  2  3  4  c. were aligned with evidence from my principal evaluations or leadership framework 1  2  3  4  d
. sent a consistent message about specific actions I can take to facilitate school improvement 1  2  3  4  e . engaged me in setting specific goals to improve my school leadership 1  2  3  4  f
. provided me opportunities to improve aspects of my work 1  2  3  4  g . helped me pay closer attention to particular things I was doing in my work 1  2  3  4  h
. led me to try new things in my practice or work 1  2  3  4  i
. helped me think about what supports teachers need to improve their practice 1  2  3  4  j
. gave me specific information about steps I can take to improve teaching in my school 1  2  3  4  k
. taught me how to gather and analyze evidence about the instructional quality in my school 1  2  3  4  l
. gave me specific information about how to effectively provide feedback to teachers 1  2  3  4 Prepared by Mathematica Policy Research 5

Next , please answer the following questions about your participation in activities specifically provided by the Center for Educational Leadership (CEL). **A 4**  **. Between June 1, 2015 and today** **, d id you participate in at least one**  **formal group training session provided by the Center fo**  **r Educational Leadership (CEL) ? Please do**  **not consider**  **CEL coaching sessions in this reply. We’ll ask separately about coaching below.**   Yes
................................ ................................ ................................ ........................ 1  No
................................ ................................ ................................ ......................... 0 **GO TO A** **6 A** **5 .**  **Thinking back across all the CEL formal group training**  **sessions in which you participated since**  **June 1, 2015 ,**  **please indicate the**  **extent to which you agree**  **or disagree with the**  **following statements. T**  **he formal group training sessions...** IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a. were well organized 1  2  3  4  b. were useful 1  2  3  4  c. gave me a clear understanding of the immediate, specific actions I could take in response to the training 1  2  3  4  d. suggested specific actions that I am likely to implement in my practice 1  2  3  4  e . helped me identify ways to measure progress toward school improvement goals 1  2  3  4  f
. helped me make more accurate assessments of teacher performance 1  2  3  4  g . helped me better manage my time and resources 1  2  3  4  **A 6**  **. Between June 1, 2015 and today** **, d id you participate in at least one**  **coaching session**  **provided by CEL** **?**  Yes
................................ ................................ ................................ ........................ 1  No
................................ ................................ ................................ ......................... 0 **GO TO B1** Prepared by Mathematica Policy Research 6

**A 7**  **. Thinking back across all the CEL**  **coaching sessions in which you participated**  **since J une**  **1, 2015 ,**  **please indicate the**  **extent to which you agree**  **or disagree with the following**  **statements. T**  **he coaching**  **sessions...** IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a. were well organized 1  2  3  4  b. were useful 1  2  3  4  c. gave me a clear understanding of the immediate, specific actions I could take in response to the coaching 1  2  3  4  d. suggested specific actions that I am likely to implement in my practice 1  2  3  4  e . helped me identify ways to measure progress toward school improvement goals 1  2  3  4  f
. helped me make more accurate assessments of teacher performance 1  2  3  4  g . helped me better manage my time and resources 1  2  3  4 Prepared by Mathematica Policy Research 7 **SECTION B. LEA DERSHIP PRA** **CTICE** The next section includes questions about the day -to-day practices you used this school year to conduct your work as principal of your school. **B1. During the 2015** **- 2016 school year, to what extent did you use teacher performance data**  **(which may come from various sources, su ch as student assessments, teacher**  **evaluations, observations of classroom teaching, teacher portfolios, or attainment of student learning objectives) to do the following**  **?**
IN EACH ROW

, MARK ONE BOX ONLY Not at All To a Small Extent To a Moderate

Extent To a Great

Extent a. Make teacher retention or promotion decisions 1  2  3  4  b. Assign or reassign teachers to grade-levels or students 1  2  3  4  c. Determine the content of professional development for school staff 1  2  3  4  d
. Identify teachers suited to leadership or mentoring positions 1  2  3  4  **B2 .**  **Please indicate the extent to which you agree or disagree**  **with the following statement .**  **During the 2015 -** **2016 school year, I**  **changed instructional assignments to match**  **teachers’ expertise with student needs**  **.**  Strongly disagree
................................ ................................ ................................ .. 1  Disagree
................................ ................................ ................................ ............... 2  Agree
................................ ................................ ................................ .................... 3  Strongly agree
................................ ................................ ................................ ...... 4Prepared by Mathematica Policy Research 8

**B3 .**  **Please indicate the extent to which you agree or disagree with the following statements. When making decisions during the 2015** **- 2016 school**  **year about what**  **formal p**  **rofessional development**  **opportunitie s (such as workshops, conferences, seminars, or in**  **- service**  **training) and other instructional supports (such as coaching or mentoring, joint lesson planning, classroom observations, or feedback on**  **instruction) to offer teachers in my**  **school, I prioritized ...**  IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a. aligning professional development to teachers’ own improvement goals 1  2  3  4  b
. aligning professional development to school-wide goals or plans for improvement 1  2  3  4  c. aligning professional development with evidence from teacher performance evaluations, observations of their teaching , or their students’ performance data 1  2  3  4  d
. ensuring that professional development deepens or builds upon teachers’ identified strengths 1  2  3  4  e . ensuring that professional development addresses the pressing issues in teachers’ classrooms 1  2  3  4  f
. ensuring that professional development sessions send a consistent message about specific actions teachers can take to improve their teaching 1  2  3  4  g . d ifferentiating professional development to meet the needs of individual teachers 1  2  3  4  h
. tailoring professional development for teachers to develop leadership skills or leadership opportunities, such as leading task forces or meetings 1  2  3  4  i
. aligning professional development to student needs that are not currently being met by school staff 1  2  3  4 Prepared by Mathematica Policy Research 9

**B4 .**  **Please indicate the extent to which you agree or disagree with the following statements. D**  **uring the 2015 -** **2016 school year , I...**  IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a . tracked whether teachers were engaging in professional development 1  2  3  4  b
. encouraged teachers to implement what they learned in professional development 1  2  3  4  c. engaged teachers in setting goals for their teaching 1  2  3  4  d
. delegated work in planning professional development for teachers to other members of my staff 1  2  3  4  **B 5** **. During the 2015** **- 2016 school year, did your school have a team of staff members that had**  **responsibility for overseeing, managing, or coordinating ins** **truction in the school ?**   Yes
................................ ................................ ................................ ........................ 1  No
................................ ................................ ................................ ......................... 0 **GO TO B** **9 B** **6 .**  **D uring the 2015** **- 2016 school year** **, h ow often did**  **you interact with members of this**  **team about instruction in the school**  **?**  Never
................................ ................................ ................................ .................... 0  Yearly
................................ ................................ ................................ .................... 1  Quarterly
................................ ................................ ................................ ............... 2  Monthly
................................ ................................ ................................ ................. 3  Weekly
................................ ................................ ................................ .................. 4 **B 7**  **. Dur** **ing the 2015 -** **2016 school year, please indicate**  **the extent**  **to which you agree or**  **disagree with the following statements about**  **this team**  **. The members of the team...**  IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a. openly express their professional views during meetings 1  2  3  4  b. are willing to question one another’s views 1  2  3  4  c. work together closely to lead this school 1  2  3  4  d. equally share power to make decisions 1  2  3  4 Prepared by Mathematica Policy Research 10

**B 8**  **. Dur** **ing the 2015 -** **2016 school year, please indicate the extent to which you agree or disagree with the following statements about your school’s leadership team.**  **I delegated responsibility to my school leadership team to...**  IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a. coach teachers on their instruction 1  2  3  4  b. conduct observations of classroom teaching 1  2  3  4  c. conduct walkthroughs in the school 1  2  3  4  d. provide other instructional supports to teachers 1  2  3  4 

**B 9**  **. Please indicate the extent to which you**  **agree or disagree**  **with the following statement s**  **.** IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a. I know what effective teaching looks like 1  2  3  4  b
. I know what teaching practices to look for when I’m conducting classroom observations 1  2  3  4  c. I feel comfortable having difficult conversations with teachers in my school 1  2  3  4  d
. I feel comfortable suggesting specific teaching actions to teachers, based on student achievement data, teacher effectiveness data, or classroom observation data 1  2  3  4 
e . I feel competent helping teachers identify their areas of instructional practice that need improvement 1  2  3  4  f
. I feel competent helping teachers recognize their accomplishments or identify their areas of strength 1  2  3  4  g . I know how to ask teachers questions soliciting their own reflection on teaching practices 1  2  3  4  h
. I know how to give teachers feedback on their instruction that provides them with actionable steps for improvement 1  2  3  4 Prepared by Mathematica Policy Research 11

**B 10**  **. Thinking about all the times during the 2015** **- 2016 school year that**  **you went to**  **a typical teacher’s classroom to observe their**  **teaching ,**  **wh at is your best estimate of the total**  **number of observations that you conducted in a typical teacher’s classro** **o m**  **?** TOTAL NUMBER OF OBSERVATION S  No observations made
................................ ................................ ........................ 0 **GO TO B**  **1 2**  **B1 1**  **. Thinking about all the times during the 2015** **- 2016 school year that**  **you visited**  **a ty** **pical teacher’s classroom to observe their**  **teaching ,**  **wh at is your best estimate of the duration**  **(in minutes) of each of the following ?**  a. A TYPICAL OBSERVATION THAT YOU CONDUCTED NUMBER OF MINUTES b. THE SHORTEST OBSERVATION THAT YOU CONDUCTED NUMBER OF MINUTES c. THE LONGEST OBSERVATION THAT YOU CONDUCTED NUMBER OF MINUTES **B1 2**  **. P**  **lease indicate the**  **extent to which you agree**  **or disagree with the following statements**  **about classroom observations of teacher instruction in your school .**  **During the 2015 -** **2016 school year, you or anyone else who conducted classroom observations...**  IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a. recorded their observations in standardized protocols or forms 1  2  3  4  b. relied on a conceptual framework to guide their observations of specific practices 1  2  3  4  c. focused their observations on specific areas or issues unique to the teacher’s needs 1  2  3  4  d. focused on recording objective descriptive evidence of what was happening in the classroom (e.g., “multiple students raised hands to respond to questions, students asked many questions, students spoke energetically with each other while solving the problem”) rather than evaluative evidence (e.g., “students were engaged”) 1  2  3  4 

e . recorded descriptions of specific things that the teacher and students did or said during a classroom observation 1  2  3  4  f
. analyzed data collected during classroom observations to identify trends in instructional practice, such as changes over time or patterns across grade levels, disciplines, or different populations of students 1  2  3  4 Prepared by Mathematica Policy Research 12

**B13 .**  **P lease indicate**  **the extent**  **to which you agree or disagree**  **with the following statements about**  **plans for improvement in your school**  **. D**  **uring the 2015 -** **2016 school year ...**  IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree a. The administration collaborated with teachers collaboratively to shape the plans in my school 1  2  3  4  b. Plans detailed the measures that would be tracked to measure progress toward goals 1  2  3  4  c. Plans were aligned with evidence from teacher performance evaluations, observations of classroom teaching, or student performance data 1  2  3  4  d
. Plans were consistent with teachers’ goals for individual growth 1  2  3  4  e . Plans clearly outlined steps that teachers should take to improve their teaching 1  2  3  4  **B14 .**  **During the 2015 -** **2016 school year, how often did**  **you d o**  **the following?** IN EACH ROW

, MARK ONE BOX ONLY Never Yearly Quarterly Monthly Weekly a. Communicate my goals for improving instructional quality in our school to teachers or other school staff 0  1  2  3  4  b. Update staff on progress toward the school vision or goals for improvement 0  1  2  3  4  c. Incorporate a clear vision for our school into my regular communications 0  1  2  3  4  d
. Delegate these actions surrounding school culture and vision to another member of my staff 0  1  2  3  4 Prepared by Mathematica Policy Research 13 **SECTION C. DISTRICT & SCHOOL CONTEXT** Next, please answer the following questions about the district and school contexts in which you operated this year. **C1 .**  **Please indicate the extent to which you agree**  **or disagree with the following statements**  **about your school district .** 
IN EACH ROW

, MARK ONE BOX ONLY Strongly Disagree Disagree Agree Strongly Agree Don’t Know a. The school district’s curriculum frameworks are specific and clear 1  2  3  4  n  b. The school district’s assessment program provides specific and clear information about what students should know and be able to do 1  2  3  4  n  c. The school district’s instructional policies give teachers clear information about what and how to teach 1  2  3  4  n  d. District standards for student learning drive much of our improvement agenda in this school 1  2  3  4  n  e . The school district is an important source of funding for our school improvement agenda 1  2  3  4  n  f
. The school district provides flexibility in how resources are allocated at this school (e.g., time, materials, personnel) 1  2  3  4  n  g . The school district’s staff provides important information and expertise that support our school improvement efforts 1  2  3  4  n  h
. There is a great deal of turnover in the central office in the district 1  2  3  4  n  i
. There is a strong consensus among district leaders about priorities for school improvement 1  2  3  4  n  j
. Central office policies and procedures change frequently in this district 1  2  3  4  n  k
. The school district’s improvement agenda makes it difficult for us to create a school improvement plan tailored to the specific needs of this school 1  2  3  4  n  l
. The district’s personnel policies and practices make it difficult to hire staff with the expertise and interest we need for school improvement 1  2  3  4  n Prepared by Mathematica Policy Research 14

**C2. During the 2015** **- 2016 school yea**  **r , to what extent did you feel you had autonomy when you**  **were making decisions about or taking actions in the following areas ?**  IN EACH ROW

, MARK ONE BOX ONLY Not at All To a Small Extent To a Moderate

Extent To a Great

Extent a. Recruiting, interviewing, hiring, dismissing, or promoting staff, assigning teachers to grades and students, planning professional development activities for staff, and other activities related to managing your school staff 1  2  3  4  b. Observing classroom instruction, providing feedback to teachers on their instructional practice, taking steps to align curriculum, assessments, or standards , and other activities related to supporting instruction in your school 1  2  3  4 
c. Planning school improvements, setting and communicating school improvement goals, communicating progress towards school improvement, community/parent outreach, student affairs, and other activities related to operations, finances, and administration of your school 1  2  3  4 Prepared by Mathematica Policy Research 15

**C3. During the 2015** **- 2016 school yea**  **r ,**  **to what ex tent was each of the following**  **a “roadblock” that prevented your school from improving**  **?** IN EACH ROW

, MARK ONE BOX ONLY Not at All To a Small Extent To a Moderate

Extent To a Great

Extent a. Lack of support from external organizations (e.g., universities, businesses, reform groups, educational consultants, etc.) 1  2  3  4  b. Pressure to constantly adopt new programs 1  2  3  4  c. Pressure to get test scores up quickly 1  2  3  4  d
. Pressure to obtain external funds 1  2  3  4  e . Disagreements or lack of coordination among school partners 1  2  3  4  f
. Lack of teacher knowledge and skills 1  2  3  4  g . Faculty apathy and resistance to change 1  2  3  4  h
. Teacher turnover 1  2  3  4  i
. Difficulty recruiting and hiring the right teachers 1  2  3  4  j
. Difficulty removing poor teachers 1  2  3  4  k
. Lack of time to evaluate teachers 1  2  3  4  l
. State or federal mandates (NCLB, desegregation, special education, bilingual education, etc.) 1  2  3  4  m . Mistrust between teachers and parents 1  2  3  4  n . Parents apathetic or irresponsible about their children 1  2  3  4  o . Problem students (apathetic, hostile, etc.) 1  2  3  4  p . Lack of support from the school’s community 1  2  3  4  q . Social problems in the school’s community (poverty, gangs, drugs, etc.) 1  2  3  4  r. Racial or ethnic tensions in the school’s community 1  2  3  4  s . Negative stereotypes about this school’s community 1  2  3  4 Prepared by Mathematica Policy Research 16

**C4. During the 2015** **- 2016 school yea**  **r ,**  **to what extent was each of the following a problem in your school**  **?** IN EACH ROW

, MARK ONE BOX ONLY Not at All To a Small Extent To a Moderate

Extent To a Great

Extent a. Student absenteeism 1  2  3  4  b. Widespread disorder in classrooms 1  2  3  4  c. Robbery, theft, or vandalism at school 1  2  3  4  d
. Students’ use of alcohol or illegal drugs 1  2  3  4  e . Student racial tensions 1  2  3  4  f
. Bullying or harassment among students 1  2  3  4  g . Physical conflicts among students 1  2  3  4  h
. Student acts of disrespect for teachers 1  2  3  4  i
. Conflicts between students and teachers or verbal abuse of teachers 1  2  3  4 Prepared by Mathematica Policy Research 17 **SECTION D. PRINCIPA** **L CHA** **RA CTERISTICS**  You ’re almost done! In this last section, please tell us about your background and experience as an educator
. **D1. What is the highest degree you have earned?**  Select one only  Associate’s degree
................................ ................................ ............................... 1  Bachelor’s degree (B.A., B.S., etc.)
................................ ................................ ...... 2  Master’s degree (M.A., M.A.T., M.B.A., M.Ed., M.S., etc.)
................................ ... 3  Educational specialist or professional dipl om a (at least one year beyond master’s level)
................................ ................................ ................................ ....... 4  Doctorate or first professional degree (Ph.D., Ed.D., M.D., L.L.B., J.D., D.D.S.)
................................ ................................ ................................ .................. 5  Do not have a degree
................................ ................................ ........................... 6 **D 2**  **. How many years have you**  **served in any administrative position**  **in this**  **school ?**  **(P lease**  **round up to the nearest whole number and include the current school year .** **)** YEARS IN THIS SCHOOL **D3 .**  **How many years have you served in**  **any administrative position in**  **any school?**  **(P lease**  **round up to the nearest whole number and include the current school year** **. )**  YEARS IN ANY SCHOOL
**D 4** **. How many years have you**  **served as principal in**  **this school**  **? (P**  **lease round up to the nearest whole number and include the current school year** **. )**  YEARS IN THIS SCHOOL **D5 .**  **How many years have you served as principal in**  **any school?**  **(P lease round up to the**  **nearest whole number and include the current school year .** **)** YEARS IN ANY SCHOOL
**D 6** **. How many years**  **of classroom teaching experience do you have**  **in any**  **school ?**  **(P lease**  **round up to the nearest whole number and include the current school year** **. )**  YEARS OF EXPERIENCE IN ANY SCHOOLPrepared by Mathematica Policy Research 18

**D 9**  **. Are you of Hispanic or Latino origin?**   Yes
................................ ................................ ................................ ........................ 1  No
................................ ................................ ................................ ......................... 0 **D 10**  **. What is your race?**  Select all that apply  Am erican Indian or Alaska Native
................................ ................................ ........ 1  Native Hawaiian or other Pacific Islander
................................ ............................. 2  Asian
................................ ................................ ................................ ..................... 3  Black or African American
................................ ................................ .................... 4  Wh ite
................................ ................................ ................................ ..................... 5 **D 11**  **. Are you male or female?**   Male
................................ ................................ ................................ ...................... 1  Female
................................ ................................ ................................ .................. 2 **D 1**  **2 .**  **In what year were you born?** YEAR

YYYY 19