2008-09 Participant Response Form

No Child Left Behind (NCLB) Act Improving Teacher Quality State Grants Title II, Part A, Subpart 3 2015-2016 Participant Response Form

Name ______Date ______

Instructions: Please mark only one answer for each question (except where indicated) for the response you feel best answers your question.

1. Professional level upon entrance into program: a. Teacher, in-service b. Administrator c. Paraprofessional (with 2 years classroom experience only) d. Other (Explain) ______

2. Highest degree earned: a. Baccalaureate b. Masters c. Doctorate d. Other

3. Licensure status: a. Certified b. Not Certified c. Provisional d. Emergency

4. Years of experience: ______

5. Number of hours beyond Baccalaureate degree: ______

6. Where do you teach? a. Public school division ______(**Specify division code; please see Code List on Pages 3 & 4) b. Private school (Specify name) ______c. Not currently teaching d. Preparing to teach

7. If you are an in-service teacher, what level do you teach? __ Elementary __ Middle School __ High School

This questionnaire will be used in compiling a statewide report to the federal government. It will not be used in evaluating the program in which you participated.

NCLB Participant Response Form Page 1 of 4 SCHEV 2015-2016 8. If you are a paraprofessional, what level are you? __ Elementary __ Middle School __ High School

9. If you are an administrator, what level are you? __ Elementary __ Middle School __ High School

10. Endorsement area: a. English b. Mathematics c. Reading or Language Arts d. Science e. Foreign Languages f. Civics and Government g. Economics h. Arts i. History j. Geography k. Other

11. This Improving Teacher Quality (ITQ) project core academic area(s) is/are: a. English b. Mathematics c. Reading or Language Arts d. Science e. Foreign Languages f. Civics and Government g. Economics h. Arts i. History j. Geography k. Other

12. Please list the subjects you teach: ______

13. What is the number of K-12 students you serve? ______

14. Indicate the purpose for participating in this ITQ project activity: a. Professional development b. Retraining for a teacher not currently endorsed in this subject. If retraining, did this activity allow you to complete necessary certification? Yes ___ No ___ c. Other (Explain) ______

15. Please indicate your race/ethnicity: a. Black, non-Hispanic b. White, non-Hispanic d. Hispanic e. Asian/Pacific Islander f. American Indian/Alaskan Native

NCLB Participant Response Form Page 2 of 4 SCHEV 2015-2016 g. Other (indicate)

16. Please indicate your gender: a. Male b. Female

17. Did this activity take into account the needs of historically underrepresented and underserved students/groups? c. Yes d. No e. Not Sure

NCLB Participant Response Form Page 3 of 4 SCHEV 2015-2016 DIVISION CODES COUNTIES CITIES

ACCOMACK 001 KING & QUEEN 049 ALEXANDRIA 101 ALBEMARLE 002 KING WILLIAM 050 BEDFORD 140 ALLEGHANY HIGHLANDS099 LANCASTER 051 BRISTOL 102 AMELIA 004 LEE 052 BUENA VISTA 103 AMHERST 005 LOUDOUN 053 CHARLOTTESVILLE 104 APPOMATTOX 006 LOUISA 054 CHESAPEAKE 136 ARLINGTON 007 LUNENBURG 055 COLONIAL HEIGHTS 106 AUGUSTA 008 MADISON 056 COVINGTON 107 BATH 009 MATHEWS 057 DANVILLE 108 BEDFORD 010 MECKLENBURG 058 FAIRFAX CITY 134 BLAND 011 MIDDLESEX 059 FALLS CHURCH 109 BOTETOURT 012 MONTGOMERY 060 FRANKLIN CITY 135 BRUNSWICK 013 NELSON 062 FREDERICKSBURG 110 BUCHANAN 014 NEW KENT 063 GALAX 111 BUCKINGHAM 015 NORTHAMPTON 065 HAMPTON 112 CAMPBELL 016 NORTHUMBERLAND 066 HARRISONBURG 113 CAROLINE 017 NOTTOWAY 067 HOPEWELL 114 CARROLL 018 ORANGE 068 LEXINGTON 137 CHARLES CITY 019 PAGE 069 LYNCHBURG 115 CHARLOTTE 020 PATRICK 070 MANASSAS CITY 143 CHESTERFIELD 021 PITTSYLVANIA 071 MANASSAS PARK 144 CLARKE 022 POWHATAN 072 MARTINSVILLE 116 CRAIG 023 PRINCE EDWARD 073 NEWPORT NEWS 117 CULPEPER 024 PRINCE GEORGE 074 NORFOLK 118 CUMBERLAND 025 PRINCE WILLIAM 075 NORTON 119 DICKENSON 026 PULASKI 077 PETERSBURG 120 DINWIDDIE 027 RAPPAHANNOCK 078 POQUOSON 142 ESSEX 028 RICHMOND 079 PORTSMOUTH 121 FAIRFAX 029 ROANOKE 080 RADFORD 122 FAUQUIER 030 ROCKBRIDGE 081 RICHMOND CITY 123 FLOYD 031 ROCKINGHAM 082 ROANOKE CITY 124 FLUVANNA 032 RUSSELL 083 SALEM 139 FRANKLIN 033 SCOTT 084 SOUTH BOSTON 133 FREDERICK 034 SHENANDOAH 085 STAUNTON 126 GILES 035 SMYTH 086 SUFFOLK 127 GLOUCESTER 036 SOUTHAMPTON 087 VIRGINIA BEACH 128 GOOCHLAND 037 SPOTSYLVANIA 088 WAYNESBORO 130 GRAYSON 038 STAFFORD 089 WILLIAMSBURG- GREENE 039 SURRY 090 JAMES CITY 131 GREENSVILLE 040 SUSSEX 091 WINCHESTER 132 HALIFAX 041 TAZEWELL 092 HANOVER 042 WARREN 093 TOWNS HENRICO 043 WASHINGTON 094 HENRY 044 WESTMORELAND 095 COLONIAL BEACH 202 HIGHLAND 045 WISE 096 WEST POINT 207 ISLE OF WIGHT 046 WYTHE 097 KING GEORGE 048 YORK 098

NCLB Participant Response Form Page 4 of 4 SCHEV 2015-2016