Name_________________________________________________________________________

What you like to be called __________________________________________________

Country, City_________________________________________________________________
Native Language_____________________________________________________________
Other Languages you speak_________________________________________________

How long have you studied English? (Circle)

1-2 Years

2-4 years

How long have you lived in the US?

1-2 Years

4 or more years
(Circle)

2-4 years

What is your highest degree?

Less than a year

Less than a year

4 or more years

(Circle)

High School

University

Masters

Doctorate

What did you study?

Why do you want to learn English? (X all that are true)
Get a job

Get a better job

Speak better

Read and write better

To learn about American Culture

Improve your grammar

For testing like the TOFEL

Other:___________________________________________________

Do you have a job? If so, where do you work?

How many hours a week do you work? (circle)
Less than 10hours

10-20 hours

20-40 hours

What do you like to do in your free time?

What activities help you learn English? (X all that are true)

Watching TV/Movies
Field Trips
Games
Reading
Listening to the Radio or Audio files
Pair/Group work
Pronunciation drills
Conversation
Listening to songs
Writing
Grammar practice
Other:________________________________________

What do you find interesting? (X all that are true)

American Culture
Global Issues
Politics
Culture
Food/cooking
Sports
Jobs
Pop Culture (Music, movies, fashion, etc.)
Technology
Other:__________________________________________

What do you enjoy reading? (X all that are true)

40hours+

Magazines
Short stories
Fairytales
Comic books/Graphic novels
Newspapers
Books
Other____________________________________________________________________

Do you have a computer or laptop to use for homework?

Do you have a smartphone, tablet or iPad to use in class?

Is there anything else you want me to know?