Field Test of student involvement survey

Appendix G: Teacher Survey of Student Involvement

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OMB No. 0000-0000
Expiration Date: xx/xx/xxxx

Classroom Assessment FOR Student Learning Study

Teacher Survey of Student Involvement
Occurring from Month DD, 200X through Month DD, 200X

Please provide the information below, then click Next to enter the survey.

First name:

Last name:

School name:

The U.S. Department of Education wants to protect the privacy of individuals who participate in surveys. Your answers will be combined
with other surveys, and no one will know how you answered the questions. This survey is authorized by law (1) Sections 171(b) and 173 of
the Education Sciences Reform Act of 2002, Pub. L. 107-279 (2002); and (2) Section 9601 of the Elementary and Secondary Education Act
(ESEA), as amended by the No Child Left Behind (NCLB) Act of 2001 (Pub. L. 107-110). Responses to this data collection will be used
only for statistical purposes. The reports prepared for this study will summarize findings across the sample and will not associate responses
with a specific district or individual. We will not provide information that identifies you or your district to anyone outside the study team,
except as required by law.
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 xxxx-xxxx. The time required to complete this
information collection is estimated to average 10 minutes per respondent, including the time to review instructions, 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 20202-4651. If you have comments or
concerns regarding the status of your individual submission of this form, write directly to: Sandra Garcia, Institute of Education Sciences,
555 New Jersey Avenue, S.W., Room 506C, Washington, D.C. 20208-4651.

Next >

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We are interested in the frequency of various activities that occurred
in your math classroom during the period between DD/MM and
DD/MM.
How many days of regular instruction were there in this time period (excluding
any teacher inservice days, field trips, etc.)?
Number of instructional days between DD/MM
and DD/MM

On how many different days during the time between DD/MM and
DD/MM did you have most or all of your students do the following
activities? Please enter the number of different instructional days for
each of the following items. For example, if you had most or all of
your students discuss learning objectives on 3 different days during
the time between DD/MM and DD/MM, you would enter ‘3’ for
Number 1.
Number of days:
1. Participate in a guided discussion of the learning objectives
in math.
2. Explain in their own words what they are supposed to be
learning in math.
3. Identify samples of their own high quality work in math.
4. Use a scoring guide or rubric to evaluate their own work in
math class.
5. Revise their own math work to make it stronger in quality.
6. Keep a record of their own learning progress in math.
7. Explain in their own words what they know how to do well
in math.
8. Explain in their own words what they need to do to improve
their math skills.
9. Identify examples of strong and weak anonymous student
work in math.
10. Comment on the quality of anonymous math work using a
scoring guide or rubric.
11. Explain in their own words what was wrong with a math
answer or piece of math work.
12. Explain in their own words how to correct a math answer
or improve a piece of math work.
13. Work together to correct errors in their math assignments.
14. Make up practice math problems.

Thank you for completing the Teacher Survey of Student
Involvement!
Click the Finish button below to submit your survey.
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Finish

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