Coach/Teacher Background Form

^{OMB Control #: XXXX-XXXX}

Coach Background Form

TO BE COMPLETED BY COACHES IN BOTH HIGH AND LOW INTENSITY SITES

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to identify teacher practices for supporting children’s social-emotional development and to identify training and implementation factors that may enhance these practices. Public reporting burden for this collection of information is estimated to average 6 minutes per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. Additionally, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB number for this information collection is OMB Control #: XXXX-XXXX and it expires on [DATE]. If you have any comments on this collection of information, please contact [NAME AND CONTACT INFORMATION].

Instructions: These questions are about you, your training, education, and years of experience coaching.

1. What is your gender?

   1. Female

   2. Male

   3. Non-binary

   4. Transgender

   5. Other

   6. Prefer not to say

2. What is your Ethnicity?

   1. Hispanic or Latino

   2. Not Hispanic or Latino

3. What is your Race? (Select one or more)

   1. American Indian or Alaska Native

   2. Asian

   3. Black or African American

   4. Native Hawaiian or Other Pacific Islander

   5. White

4. What is the highest level of formal education that you have completed?

   1. An advanced degree or license (including a master’s degree)

   2. Associate’s degree

   3. Bachelor’s degree

   4. Studies leading to a non-degree license, certificate, or credential

5. Do you have any training, or experience with using trauma-informed approaches in the classroom? (That is, understanding how trauma can impact young children’s learning and behavior and finding ways to better support them)?

   1. No

   2. Yes [please describe]

6. Do you have any training, or experience related to promoting young children’s social-emotional development?

   1. No

   2. Yes [please describe]

7. How long have you been working as a coach? [Drop-down menu]

   1. This is my first year

   2. 1 year

   3. 2 years

   4. 3 years

   5. 4 years

   6. 5 years

   7. 6 years

   8. 7 years

   9. 8 years

   10. 9 years

   11. 10+ years

8. How long have you been working as a coach at this Center? [Drop-down menu]

   1. This is my first year

   2. 1 year

   3. 2 years

   4. 3 years

   5. 4 years

   6. 5 years

   7. 6 years

   8. 7 years

   9. 8 years

   10. 9 years

   11. 10+ years