CEP 2014 - Integrated Skills

Background and Self-assessment Questionnaire

Last Name: ___________________________________ First Name: __________________________________________
Email: _________________________________________ Nationality: __________________________________________
Gender:

Male

Female

Native Language: ___________________________________

1. Number of years I have studied English: _________________________________________________________

2. Have you taken classes at the CEP before? If so, which classes? ______________________________
2. Number of years I have lived in the US: ___________________________________________________________
3. Language(s) I speak other than English: _________________________________________________________

4. What is the highest level of education that you have completed? (Check one.)
High school
Bachelors degree
Graduate degree (Masters, Professional, or Doctorate)
Other: ____________________________________

5. Self-Assessment of English Language Skills

Directions: For each area listed below, place a check mark in the column that best describes your
skill level.

5 = very strong

4 = strong

3 = average

2 = weak

1 = very weak

Speaking
Listening
Reading
Writing
Grammar
Vocabulary

6. Personal Learning Preferences

Directions: For each of the following, place a check mark in the column that best describes your
feelings about the following activities.

5 = Enjoy it

4 = Comfortable

3= No preference

2 = Uncomfortable

1 = Dislike it

Working in groups
Working with a partner
Public Speaking
Using technology
Grammar
Vocabulary

7. What are your goals for learning English? (check all that apply)
get a job

improve your speaking

improve your writing

improve your reading

improve conversation skills prepare for a test

improve your grammar

learn about American culture

other: ______________________________________________________________

8. What topics do you find interesting? (check all that apply)

American culture

social networking

global issues

the arts

food/cooking

sports

business

travel

fashion

music

technology

other: ______________________

9. Do you own or have access to the following technology?

computer/laptop

internet

printer

tablet (iPad)

10. Have you ever written an academic research paper? (in English or your native language)

11. Writing Sample

Directions: Please write 4-5 sentences about yourself. For example, you may describe your job, your
family, or your favorite hobbies. This is to help me to get to know you!
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