The Adult Basic Education Teacher's Toolkit

Appendix A
Forms

Appendix A: Forms

This appendix contains the following forms.

The Student Information Sheet
Concept and Writing Checklist
KWL
Narrative Frame 1
Narrative Frame 2
Narrative Frame 3
Narrative Frame 4
Narrative Frame 5
Plan Think Sheet
Organize Think Sheet
Edit Think Sheet
Revise Think Sheet
Word Map
Strategy for Analyzing Word Problems

Have students fill out this form. Use the information as an informal method for getting an initial estimate of a learner's literacy skills. Three levels of skills are roughly indicated by the A, B, or C in the left margin.

A is a beginning level.
B is intermediate.
C is more advanced.

This form is relatively nonthreatening if you sit with each student to complete the information. Doing this will also give you an opportunity to learn a little about the student, which will help you when you plan learning activities that will interest this student. If you are unable to sit with each student the length of time it takes to fill out the form, at least spend several minutes with each student and get each one started.

The Student Information Sheet

1.	Write or print your name: __________________________________________________
2.	What is your address? ____________________________________________________ ______________________________________________________________________ ______________________________________________________________________
3.	What is the date today? ___________________________________________________
4.	Do you have a telephone? If so, what is the number? ___________________________
5.	Are you married? What is your husband's name (or wife's name)? ________________ ______________________________________________________________________
6.	Do you have children? If so, how many? What are their names and ages? ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
7.	When is your birthday? ___________________________________________________
8.	When were you born? ___________________________________________________

1.	Are you a citizen of the United States? No _____ Yes _________
2.	Are you a citizen by birth or by naturalization? ____________________________
3.	Do you have private transportation? No _________ Yes __________
4.	If so what type? _____________________________________________________
5.	Do you possess a valid driver's license? No _____________ Yes ____________
6.	What is your ethnic orgin? ____________________________________________
7.	Are you a registered voter in the State of Texas No ________ Yes ___________
8.	If you are presently employed, please indicate whether you are employed on a full-time or part-time basis. full-time _______ part-time _____ hrs/week
9.	What is your job title, and how long have you worked for your present employer on the job which you now hold? _________________________________________ __________________________________________________________________ __________________________________________________________________
10.	Do you subscribe to a newspaper or any magazines? No _______ Yes __________
11.	If so, please list them _________________________________________________ __________________________________________________________________ __________________________________________________________________
12.	Do you own (or have ready access to) a TV set? No ________ Yes __________
13.	Do you own a radio or is one available to you? No _____ Yes ________
14.	Please answer the following questions either - fine, good, fair, poor, or bad. a. How is your vision? ________________________________________________________ b. How is your hearing? ______________________________________________________ c. How is your general health? ________________________________________________
15.	Please write in words the number of times you estimate that you visit the doctor each year. ____________________________________________________________
16.	How did you learn about this program? __________________________________ _____________________________________________________________________
17.	Please write a brief and pertinent paragraph explaining how you were made aware of the program.
18.	Please write a paragraph that tells what your goals are and how your goals can be enhanced or furthered by this program.
19.	Please write a paragraph about yourself, as you see yourself. You may repeat information which you have already given in the above paragraph.
20.	What things do you feel will be most helpful in aiding an instructor who is trying to prepare a program of instruction suited to your particular needs?

*Adapted from a form developed by The Extension Teaching an dField Service Bureau, Division of Extension, The University of Texas at Austin. Permission to reproduce is granted to Adult Education.

Concept and Writing Checklist

3 = OK; 2 = Needs improvement; 1 = Can't tell

Criteria Student___________________

Organization of ideas

Clear topic _______________

Supporting details/examples _______________

Logical flow _______________

Comments:

Style

Shows variety in:

Word choice _______________

Sentence length _______________

Comments:

Mechanics

Complete sentences _______________

Capitalization _______________

Punctuation _______________

Comments:

K-W-L

K - What I Know	W - What I Want to Know	L - What I Learned

Narrative Frame 1

Narrative Summary with one character included

Our story is about________________________________________________________.

_____________________________________________ is an important character in our

story. _______________________________ tried to ___________________________

The story ends when_____________________________________________________

_________________________________________________________________________

_________________________________________________________________.

Narrative Frame 2

Important idea or plot

In this story the problem starts when _________________________________________.

After that _______________________________________________________________ .

Next, ___________________________________________________________________

_______________________________________________________________________ .

Then __________________________________________________________________ .

_________________. The story ends when ___________________________________

___________________________________________________________________________

______________________________________ .

Narrative Frame 3

Setting

This story takes place when ________________________________________________.

I know this because the author uses the words ________________________________

__________________________________________________________________________

Other clues that show where the story takes place are __________________________

__________________________________________________________________________

_________________________________________________________________.

Narrative Frame 4

Character Analysis

_________________________________________________ important character in the

story. ________________________________________________________is important

because ________________________________________________________________ .

Once, he/she ____________________________________________________________

__________________________________________________________________________

Another time, ______________________________________________________________

____________________ . I think that ___________________________________________

____________(name)_________ is _________________________________ (trait)

_______________________because ____________________________________________

____________________________________________________________________ .

Narrative Frame 5

Character Comparison

_____________________________ and ____________________________________are

two characters in the story. __________(name) ________________________is

________________________________(trait)___________________________

while ___________(name)______________________ is _________________

__(trait)____________________________________________________________

For instance, __________________________________________________________ tries

to __________________________ and _____________________________________ tries

to ___________________________________ .

Plan Think Sheet

Author's name ________________________________ Date____________________

Topic ____________________________

Who: Who am I writing this for?

Why: Why am I writing this?

What: What do I already know about my topic?

1. _________________________________________________________________________

2. _________________________________________________________________________

3. _________________________________________________________________________

4. _________________________________________________________________________

5. _________________________________________________________________________

How: How do I group my ideas?


_____________________ _____________________ _____________________		_____________________ _____________________ _____________________

_____________________ _____________________ _____________________		_____________________ _____________________ _____________________

Organize Think Sheet

What is being

Explained?

Who or what

is needed?

Setting?

What are the steps?

First:

Third:

Then:

Fifth:

Finally:

Edit Think Sheet

Read to check your information

What do I like best? Why?

What parts are not clear? Why not?

Question yourself to check organization

Tell what was being explained?	yes	sort of	no
Tell what things are needed?	yes	sort of	no
Make the steps clear?	yes	sort of	no
Use keywords to make it clear?	yes	sort of	no
Make it interesting to my reader?	yes	sort of	no