Name: ________________________________
What country are
you from? __________________________________
What is your
native language? _________________________________
Do you speak any
other languages besides your native language? If so, list all languages _______________________________________________________________________
How often do you
speak English? ____________________________________________
Do you work now?
________________________________________________________
Where do you use
English? _________________________________________________
Why do you need
to learn English? Please be specific. Give examples of situations that are
difficult for you in English.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What specific
areas of English would you like to improve? ______________________________
When people
speak English to you, how much do you understand? Check one that applies.
______ most of
it ________some _________a little __________very little
When you watch
TV or listen to radio, how much you understand?
______ most of
it ________some _________a little __________ very little
When you speak
English, how much do other people understand?
______ most of
it ________some _________a little __________ very little
Order the skills
that you need from 1 to 6. Number 1 is the most important and number 6 is the
least important to you at this time. Please use each number only one time.
_______ Reading
_______ Writing
_______
Listening
_______ Speaking
_______ Speaking
_______
Vocabulary
_______ Pronunciation
_______ Pronunciation
_______ Grammar
How do you learn
best? Check all that applies.
_______
listening ________ touching _________ seeing _________ moving around
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