1) Name:

2) Education (degree obtained or school level attended):

3) Country of origin:

4) Country of residence:

5) If questions 3 and 4 are different, how long have you been in the country of your current residence?

6) What is your native language or languages? At what age did you begin to learn each?

7) How have you learned English up to this point? (check all that apply)

__Through formal classroom instruction

__Through interacting with people

__Online from chatting, messaging, or emailing

__From TV, music, or movies

__Other, specify:

8) In a typical day, which languages do you use at what percent?

Language ____________________: <25%         25%      50%      75%      100%

Language ____________________: <25%         25%      50%      75%      100%

Language ____________________: <25%         25%      50%      75%      100%

9) Which languages do you use in the following activities?

Listening to radio, watching TV or movies:

Reading for work:

Reading on the internet:

Writing emails to or chatting with friends:

Reading news:

Writing papers or assignments:

10. Which languages did you learn or receive instruction in at these levels?

Primary/Elementary School: __________

Secondary/Middle School: __________

High School: __________

College/University: __________

11. If you have lived or traveled in other countries for more than three months, please indicate the name(s) of the country or countries, your length of stay, and the language(s) you learned or tried to learn.

12. Is there anything else that you feel is interesting or important about your language background that you’d like me to know?

*Adapted from Rebacca Lorimer, Writing Across the Curriculum, University of Wisconsin-Madison