Building an Inclusive Classroom Summer Seminar Pre-Survey

Student Survey to Build an Inclusive Classroom

This survey will help me get to know you before the semester begins and will help me understand more about your interests, goals and strengths. It will take about 15 minutes to complete. Please complete the survey by X p.m. on [date] so that I can use the information to help prepare for the semester.

1. Your first and last name:

2. What you'd like me (the class) to call you:

3. If your name is sometimes mispronounced, please tell me how to pronounce it correctly:

4. Where did you spend the first few years of your life?

5. What is the first language you learned to speak?

6. Do you speak any other languages? Yes ______No

7. What else would you like us to know about you? What do you do in addition to being a student?

8. Please explain any personal issues that might affect your performance or experience in this class. Share any information you want me to know so that I can address your needs.