EC Twin Cities 2018-2019 Pre-Survey

In order for the tutor to provide the maximum benefit we would like to learn more about the student receiving tutoring. Please complete one survey per student who will be served one-on-one or in a small group by an Experience Corps tutor this year. Thank you for allowing us to serve you!

**Once you have answered all of the questions below, click the "Submit" button.**

SCHOOL:

1. Teacher FIRST name:

Teacher LAST name:

2. Student FIRST name:

Student LAST name:

3. Enter the first and last name of the primary EC tutor(s) who serve this student:

1st EC tutor's FIRST name:	1st EC tutor's LAST name:
2nd EC tutor's FIRST name:	2nd EC tutor's LAST name:

Student Information

4. What grade is this student in? (select one)

Pre-KindergartenKindergarten1st grade2nd grade3rd grade4th grade5th gradeOther

If "Other," specify

5. What is the student's gender? (select one)

MaleFemaleUnknown

6. What is the student's race/ethnicity? (select one)

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteMultiracialDon't Know

7. Is this student eligible for free or reduced-priced meals?

YesNoDon't know

8. Is this student identified as an English Language Learner?

YesNoDon't know

9. Please rate the student's overall reading and literacy performance (grade level proficiency at the BEGINNING of the year/tutoring match.

2 or more grade levels behind1.5 grade levels behind1 grade level behind.5 grade level behindOn or above grade level (proficient)

10. For each of the four social and emotional indicators listed below, please rate the student at the BEGINNING of the year/tutoring match. (select one for each indicator)

Participation

Very LowLowModerateHigh

Motivation

Very LowLowModerateHigh

Concentration

Very LowLowModerateHigh

Self-Confidence

Very LowLowModerateHigh

11. Assessment/Test Name

12. Assessment/Test Score

Contact Information