Sample II-10: Family Literacy Program Needs Assessment Interview (All Levels)
City:________________________ Site: _________________________________________
Date:________________________ Interviewer: ___________________________________
Information about Parent or Guardian Enrolling
Interviewer Introduction: My name is (Interviewer's Name). With your permission I would like to ask you some questions about you, your background, why you are enrolling in a class, and are enrolling (Child's Name) with you.
Parent and Child Information: First I need to get some general information about you and (Child's Name), such as your address and telephone number. (Fill in information.)
Full Name of Adult:____________________________________________________________
First Name:_________________________ Date of Birth: ____________________________
Address: ____________________________________________________________________
Telephone: ______________ Cell Phone: _________________ E-mail: __________________
Date of Enrollment:_______________ Gender:
Male
Female
1. Adult Learner Background
Interviewer Instructions: What is your race or ethnicity? (Check all responses given.)
American Indian or Alaskan Native
Asian
Native Hawaiian or Other Pacific Islander
Black or Afro-American
Hispanic or Latino
White
Other:
What is the usual (main) language spoken in your home?
English
Spanish
Other
(Specify):
Interviewer Instructions: What is the highest grade or year of schooling that you completed? (Check one.)
No schooling (skip to question #2) Completed grades 1-8 Completed grade 9 Completed grade 10 Completed grade 11 Completed grade 12, but didn't receive a diploma Completed high school and received a diploma or GED