Attended some college, no degree
Completed 2-year Associate's degree
Completed 4-year Bachelor's degree
Completed Graduate degree (Master's, Professional, or Doctorate)
Where did you go to school and complete the education mentioned above?
In the United States
In another country (Specify): __________________________________________________
What is the main reason for leaving school when you did? _______________________________
2. How did you learn about the family literacy program?
3. Information about Child to be Enrolled
Full Name of Child: ___________________________________________________________Child's Date of Birth: _______________ Gender:
Male
FemaleIs (Child's Name) enrolled in grade school now?
Yes
No
In what grade? _____Child's education before attending grade school:
Head Start
Title I Preschool
Other Preschool
Infant/Toddler Program
Kindergarten
1st grade
2nd grade
Information about Work and Family Activities
Interviewer Instructions: Please tell me about your work situation. (Read each category to the parent before asking for a response. Check one)
4. Work Situation
You are currently employed. You are currently not employed, but would like to find work. (If yes, skip to question #5.) You are currently not employed, and do not plan to seek work. (If yes, skip to question #5.)How many hours a week do you work? _____
When do you work (hours of the day)?
Day
(8-5)
Evening
Night
Rotating/Swing Shift
Are the shift changes always the same?
Yes
No
How long does it take you to go to/from work (one way) each day? Hours_____ Minutes_____
How do you get to work?
Your own car
Ride with a friend
Ride the Bus
Walk