Personal Survey

This survey will be kept confidential and will only be used to help me get to know you.
Name: 


A red asterisk (*) indicates required questions.

  1. What year in school are you?  *


  1. Please write your full name (first & last) and then give me the name you would like me to call you.*


  1. What science class did you have last year?  *


  1. If you answered "other" to the previous question, please specify which class you had. If you are a transfer student, please let me know what school you are from, the name of the last class you attended and a brief description of the class.*


  1. What was the grade you received in your last science class?   *


  1. How would you rate your relationship with your parents or guardians?*
      1 2 3 4 5  
    Excellent   Poor


  1. Do they help you with home work?*
    Yes
    No


  1. Do they encourage you to do well in school?*
    Yes
    No


  1. Do they encourage you to have other non-academic activities?*
    Yes
    No


  1. Do you have a job?*
    Yes
    No


  1. If you have a job, how many hours a week to you work? 


  1. When do you work? 


  1. Do you have any siblings that are attending Maine East now?*
    Yes
    No


  1. Do you have any siblings that graduated?*
    Yes
    No


  1. If you had siblings that graduated, when did he/she graduate and what was his/her name?


  1. Did any of them have me as their teacher?
    Yes
    No


  1. Has your experience here at ME been positive so far?*
    Yes
    No


  1. Explain your answer to the previous question.*


  1. Would you reccommend this school to your friends?*
    Yes
    No


  1. (To the previous question) Why or why not?*


  1. How important is a good education to you? ( 6 being extremely important and 1 being not important at all)*
    1 2 3 4 5 6


  1. How important is having a job to you? ( 6 being extremely important and 1 being not important at all)*
    1 2 3 4 5 6


  1. How important is having a lot of friends to you? ( 6 being extremely important and 1 being not important at all)*
    1 2 3 4 5 6


  1. How important is getting the BEST grades to you?( 6 being extremely important and 1 being not important at all)*
    1 2 3 4 5 6


  1. How important is being involved in non-academic activities to you? (non-academic includes sports, clubs, band, etc.)( 6 being extremely important and 1 being not important at all)*
    1 2 3 4 5 6


  1. Do you have a computer at home?*
    Yes
    No


  1. Do you have internet access at home?*
    Yes
    No


  1. Is there a computer in your room?*
    Yes
    No


  1. Do you have a printer hooked up to a computer at home that is in working order?*
    Yes
    No


  1. How many hours a day do you spend on the computer ( on non academic work- facebook, games, etc.)  *


  1. How many hours a day do you spend watching TV?  *


  1. Do you have a TV in your room?*
    Yes
    No


  1. List shows that you enjoy watching if any.


  1. Do you listen to music while doing homework?*
    Yes
    No


  1. Would you like to listen to music during lab?*
    Yes
    No


  1. Do you speak another language at home?*
    Yes
    No


  1. If you answered "yes" to the previous question, what language do you speak?


  1. Were you born in the U.S.?*
    Yes
    No


  1. If not, where were you born and what year did you come to the states?


  1. Do your parents speak English?*
    Yes
    No


  1. Do you have any pets?*
    Yes
    No


  1. What type of pets do you have and what are their names?


  1. What are you looking forward to most this year?*


  1. What type of learner are you? Example, do you learn better by reading the book on your own, seeing a video, looking at the board, etc.? Please explain what your preferred way of learning is.
    *


  1. How do you feel about homework? Honestly!! Are you the type of person that needs extra practice sometimes, or do you feel it is a waste of time and feels like busy work?*


  1. Do you consider yourself an organized person?*
    Yes
    No


  1. Explain why you think you are organized or unorganized. Do you feel you want to be organized and just don't have the skills or do you do better when you are unorganized?*


  1. What genre of music do you like to listen to? Choose all that apply.*
    classic rock
    rap
    ska
    country
    alternative
    dance/techno
    hard rock/heavy metal
    death metal
    classical
    other


  1. If you chose "other" to the above question, please list.


  1. Do you have a cell phone?*
    Yes
    No


  1. If you have a cell phone, what do you use it for? Do you bring it to school?


  1. Do you play a musical instrument?*
    Yes
    No


  1. If you play a musical instrument, what is it and how many hours A WEEK do you practice on average?


  1. Are you in any non-academic activities?*
    Yes
    No


  1. What type of non-academic activities do you participate in? You can list activities that are non-school sponsored as well.


  1. Do you have any type of video games in your room?*
    Yes
    No


  1. Do you drive yet?*
    Yes
    No


  1. If you drive, do you have your own car or do you borrow a car from a car?


  1. Please tell me about your family life. Is there anything I should know about that would negatively affect your grade in this class? All RESPONSES WILL BE KEPT CONFIDENTIAL!!!*


  1. Last Question!! As your teacher, what do you expect out of me? How can I best help you succeed in this class?*





Mrs. Klein
Chemistry Instructor
Maine East High School
Park Ridge, IL