Sample II-6: Beginning Level Self-Assessment Instrument

Purpose: To set personal goals and develop an individualized plan for documenting progress.

Process: Give this form to the students. Explain the meaning of "once in a while" if they don't know it. Then, give them the following prompt:

Based on home literacy activities identified in the Open-Ended Questionnaire, list activities you plan to do with your children. Indicate how often you might do each.

Family Activity Almost every day Once or twice a week Several times a month Once or twice a month Once in a while
My children and I plan to ...

go to the library		       X  
           
           
           
           
           
           

(Adapted from Holt & Van Duzer, 2000. Used with permission.)