Data Form

Student Data and Contact Information Sheet

Please circle the appropriate response or PRINT answers in English, depending on the item.


Name___________________________________________ Date________________________

How to reach you: E-mail_______________________________________________

Circle course English Language A6 Business English A6 Business English A8

1. For how many years (including 2010) have you studied English?

2. What other countries have you lived in or visited for 5-29 days (less than a month)?




3. What other countries have you lived in or visited for 30 days or more (one month or longer)?



4. Have you formally studied English in an English-speaking country for 30 days or more? Yes No

5. Does any member of your household (including you) use English as a native speaker? Yes No

6 What computer and internet skills do you have? Circle all that apply.)

E-mail Web Browsing Blogging Social Networking Website Development

I have my own website (List URL below): None, but I know what a computer looks like


7. Do you have regular access to a computer for word processing? Yes No

8. Do you have regular access to a computer with broadband internet access? Yes No

9. List THREE things that you think I, as your teacher and as a visiting professor, should know about you.




Answer the following writing sample on a separate sheet of paper. BE SURE to put your name on the paper: (I won’t evaluate this for points, although I will note if you have done it in my class participation records.)

We talked at the first class session about what we might be able to accomplish by the end of this class, and I’ll consider your comments as a class when I plan my portion of this course for the rest of the semester. But I’d also like to know what you think as an individual. In a paragraph or so, tell me 1-3 things you would like to gain from this course by the end of the semester and explain your answer.