Instructors: John Chan & Wei-Ling (Ruby) Liu

Community English Program (CEP), Teachers College, Columbia University

Level: Intermediate 3 (I3)
1. What is your name? _____________________ 2. Where are you from?____________________________
3. What is your native language? ______________ 4. How long have you lived in the US? _______________
5. How long have you studied English? _____________________
6. Did you work in your home country? If yes, what was your job? _________________________
7. Do you have a job now? If yes, what is your job and where do you work?
______________________________________________________________________
8. Describe your educational background. (ex: High school, college.)
_______________________________________________________________________
9. What kinds of things do you want to do in English? Check yes or no.

Activities

YES NO

YES NO

Watch movies or TV

Sing English songs

Read newspaper or magazines

Write e-mail

Visit websites

Write resume/cover letters

Read books/novels

Use English at work

Listen to the radio

Use English with family

Speak with people in stores/shops in English

Write papers for classes/school

What other things do you want to do with English?

________________________________________________________________________________________
10. Self-Assessment of English Language Skills
For each area listed below, place a check mark in the box that best describes your skill level.

Skills/knowledge Very poor

Poor

Average

Reading
Writing
Listening
Speaking
Grammar
Vocabulary

Good

Very Good

11. English Learning Goals

How important is it to you to focus on the following skills? Place a checkmark in the appropriate box.

Skills/knowledge

Not Important

A Little Important

Important

Very Important

Reading
Writing
Listening
Speaking
Grammar
Vocabulary
12. How much time are you able to commit to English outside the classroom per week?
Never 1-2 hrs 3-4hrs 5 or more
13. Will you be able to use any of the following for learning English? (Check all that apply)
Computer Smartphone Tablet (iPad) Internet
14. Why did you choose to take this English class?
_________________________________________________________________________________
_________________________________________________________________________________
15. Please introduce yourself briefly:

What do you like to do in your free time? What are your interests?

_________________________________________________________________________________
_________________________________________________________________________________

What are you interested in doing in the class?

_________________________________________________________________________________

_________________________________________________________________________________
16. What are some other things you want your teachers to know about you?
_________________________________________________________________________________
_________________________________________________________________________________