TEACHER DIRECTIONS FOR ADMINSTERING SURVEYS

i

Survey Assessments

-Lead students through assessments, beginning with “How I Use My Time Survey”-Some students may need these to be read to them-Use “Brain Breaks” (in student pages) as needed: directions and activity cards provided on next pages.

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1

The following surveys are intended for you and your students to get a better understanding of where they come from and what they want to do in life. They are intended to be taken once before starting the “I” in the IEP curriculum and again near its completion. Change or growth can be measured by comparing answers between the two times students complete the surveys. For example, the AIR survey is scored easily and can be taken by students as well as their parents and teachers (versions in accompanying PDF files) to gauge level of students’ self determination.

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ii

Print and cut the following cards. Randomly distribute cards to two or more students to construct the poem (following activity for second time surveying).

Read the title of the poem and the introductory stanzas. Then ask students to complete the poem together (in at least pairs), taking hints from the rhymes to guide the sequence of couplets.

The beginning student card is marked with a “1” to get students started. The other cards are not numbered. The point is to have students construct the poem using rhyming to guide which part of the poem comes next. Any poem will work if it rhymes to guide students and can be divided into couplets.

"What's all the clatter?" asked the platter.

"Teapot fell"

said the dinner bell.

"Teapot broke"

said the artichoke.

"She went ker-plop"

said the mop.

"Is she dead?"

asked the bread.

"Just a break”

I Can't Said The Ant by Polly Cameron

I was taking a walk when I heard a loud clatter,I rushed into the kitchen to see what was the matter.

There on the floor with the tea pouring outWas a cracked tea-pot with a broken spout.

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1

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iv

said the steak

"What a life"

said the knife.

"Push her up"

said the cup.

"I can't"

said the ant.

"You can"

said the pan.

"You must"

said the crust.

"Please try"

said the pie.

“You’ll have fun,”with this one.

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1

BEFORE WE BEGIN….

None of the pages that follow are graded. They simply help show what you know about yourself now, and how far you are progressing. There are lots of ways to show how far you are growing, and while these pages will help, your own sense of growth might be the most important.

What do you know about yourself now….STUDENT PACKET

1. I’d rather play video games and watch TV indoors than go outside to play.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

2. I go over what will happen over the whole day after school with my parent/guardian each morning.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

3. If I don’t get things done on time, I don’t worry about it too much.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

4. I like to think about what my life will be like when I grow up.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

5. If something I want to do is going to be really hard, I set goals with my parents/guardians in order to get it done.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

6. Doing my homework and other necessary things comes before play or watching TV after dinner.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

7. I believe that my future will be beautiful and well planned.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

8. I try to live my life as fully as possible every day.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

9. I think that it’s useless to plan too far ahead because things hardly ever come out the way you planned anyway.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

How I Use My Time Survey (Adapted from the Stanford TPI)Researchers at the University of Hawai‘i would like you to be in our study. We are asking students about their interests, how they live day to day, and how they think about their future. Your opinions are important to us, so we would like you to be honest when filling out this questionnaire. As your teacher reads the items to you, read them to yourself silently and then mark one of the boxes in each row below. After each sentence, simply reply to the question:

"How true is this of you?"How true is this of you?

Please go on to the next page 2

11. I don’t like being late for school. ☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

12. I tend to do things on impulse -making decisions before really thinking things through.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

13. I feel that it’s more important to enjoy what I’m doing than to get homework or chores done on time.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

14. I don’t do things that will be good for me if they don’t feel good right away.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

15. I tend to lose my temper if other kids tease me.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

16. It upsets me when friends are late, like if we didn’t get to go to the beach because our ride didn’t show up on time.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

17. I complete class projects on time by sticking to it and making steady progress.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

18. When I play with friends I try to take risks because it makes it more exciting.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

19. I keep working at difficult tasks or things I don’t like if it will help me get ahead at school or in life.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

20. I am able to resist temptations when I know that there is work to be done.

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

All pau…Mahalo!

"How true is this of you?

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WORK & SCHOOL IN MY FUTURE SURVEYWORK & SCHOOL IN MY FUTURE SURVEY

The purpose of this survey is to collect information on your plans after high school. This information is important because it will help us to understand your experiences in school. Please answer each question to the best of your knowledge. You may fill this out with your parent or teacher. Identification code: ___________________

Please respond to each of the following.Please respond to each of the following.1. What do you think you will do after middle school? (CHECK ONE OPTION) _____ Graduate with a regular high school diploma _____ Receive a certificate (certificate of completion, modified diploma) _____ Reach maximum age _____ Drop out _____ No Answer

2. What post-school goals are included in your educational plan for the period immediately following high school? (CHECK ALL THAT APPLY)_____ Attend a postsecondary school, training, or education program_____ Get a job. _____ Get public assistance_____ No answer

EMPLOYMENT SECTION

1. If you get a job after high school, what kind of job do you see yourself doing?

2. What is the name of the job? (write job title)___________________________________

3. Will you make minimum wage? _____ NO _____YES 4. Will you make more than minimum wage? _____ NO _____YES 5. Will you usually work more than 35 hours per week? _____ NO _____YES

POSTSECONDARY SCHOOL SECTION

6. Do you see yourself enrolled in any type of school, training, or education program after high school?_____ NO _____YES, GO TO QUESTION #7 & #8_____No Answer

Please go on to the next page

Adapted from the Post-School Data Collection Protocol developed by the National Post-School Outcomes Center Eugene, Oregon, (funded by Cooperative Agreement Number H324S040002) with the U.S. Department of Education, Office of Special Education and Rehabilitative Services

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7. Describe the kind of school or training program (CHECK ONE OPTION) _____ High school completion or certificate (e.g., Adult Basic Education, GED) _____ Short-term education or employment training program (e.g., WIA, Job Corps, etc.) _____ Vocational Technical School—less than a 2-year program _____ Community or Technical College (e.g., 2-year college) _____ College/University (e.g., 4-year college) _____ Enrolled in studies while incarcerated _____ Other (Specify): ________________________________________ No Answer

8. Do you think you will you be enrolled in school full-time once you leave high school?_____ NO _____ YES

9. Over-all, what is your educational goal for college?CHECK THE ONE THAT SHOWS YOUR HIGHEST EDUCATIONAL GOAL…._____ Get an Associates degree (2-year college)_____ Get a Bachelors degree (4-year college)_____ Get a Masters or Ph.D. degree (graduate school)_____ Get a professional degree (doctor, dentist, veterinarian, lawyer, etc.)_____ Other – describe: ___________________________________________________

10. Please describe any disabilities you have been identified with: ________________________________________________________________________________________

KNOWLEDGE OF THE IEP SECTION11. Do you know what an Individualized Education Program is? (It is often called IEP for short.)CHECK ONE OPTION…._____ No, I do not know what an IEP is_____ Yes, I know that the purpose of an IEP is (describe below): ______________________________________________________________________________________________________________________________________________

12. Do you have an IEP?CHECK ONE OPTION…._____ I do not know if I have an IEP _____ No, I do not have an IEP _____ Yes, I have an IEP

Please go on to the next page

Adapted from the Post-School Data Collection Protocol developed by the National Post-School Outcomes Center Eugene, Oregon, (funded by Cooperative Agreement Number H324S040002) with the U.S. Department of Education, Office of Special Education and Rehabilitative Services

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13. Have you ever been to a meeting about your IEP? CHECK ONE OPTION…._____ I do not remember if I have been to my IEP meeting _____ No, I have never been to my IEP meeting_____ Yes, I have been to at least one of my IEP meetings

13a. If “yes”, did you feel like adults at the meeting welcomed you and wanted to hear your opinions?

CHECK ONE OPTION…._____ I do not remember if I felt welcomed _____ No, I did not feel welcomed_____ Yes, I felt welcomed

14. Do you want to go to your next IEP meeting? CHECK ONE OPTION…._____ I do not know if I want to go to my next IEP meeting _____ No, I do not want to go to my next IEP meeting _____ Yes, I want to go to my next IEP meeting

15. If you go to your next IEP meeting, what help will you ask for so you can achieve your goals after middle or high school? Describe:______________________________________________________________________________________________________________________________________________________

Adapted from the Post-School Data Collection Protocol developed by the National Post-School Outcomes Center Eugene, Oregon, (funded by Cooperative Agreement Number H324S040002) with the U.S. Department of Education, Office of Special Education and Rehabilitative Services

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Hawaiian Culture ScaleAdapted for Middle School

We would like you to answer the following items on Native Hawaiian culture and ethnicity.

1. I learned about the Native Hawaiian way of life from my family at home. (check one)

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

2. I learned about the Native Hawaiian way of life from school. (check one)

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

3. I learned about the Native Hawaiian way of life from friends and neighbors. (check one)

☐☐Very Very truetrue

☐☐ TrueTrue

☐☐Not sureNot sure

☐☐UntrueUntrue

☐☐Very Very UntrueUntrue

4. Check anyone in your household who can carry on a conversation in Hawaiian: ___Yourself ___Mother (primary female caregiver) ___Father (primary male caregiver) ___Grandmother ___Grandfather ___Other (specify): _________________________ ___None

5. What language is primarily spoken in your home? ___Standard English ___Pidgin English ___Hawaiian ___Other (specify): __________________________

6. Do you have any Hawaiian blood? ___Yes ___No ___Don't know

7. If you answered yes above, select the one choice below that describes you: ___Pure (100%) Native Hawaiian ___Half (50% or more) Native Hawaiian ___Less than half (less than 50%) Native Hawaiian

Please go on to the next page

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Now rate yourself on the following qualities. Please check only one box which best describes you.

Qualities:

8. Rate your ability to understand the Hawaiian language.

☐Excellent

☐Good

☐Pretty good

☐Not so good

☐Not at all

9. Rate your ability to speak the Hawaiian language.

☐Excellent

☐Good

☐Pretty good

☐Not so good

☐Not at all

10. How much do you value Hawaiian beliefs, behaviors and attitudes?

☐Very much

☐A large amount

☐Some- what

☐Not so good

☐Not at all

11. How much do you value Non-Hawaiian beliefs, behaviors and attitudes?

☐Very much

☐A large amount

☐Some- what

☐Not so good

☐Not at all

12. How important is it to you to maintain Hawaiian cultural traditions?

☐Very important

☐Important

☐Somewhat important

☐Not so important

☐Not at all important

Please go on to the next page

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Brain Break

With the cards your teacher gives to you,read the cards in an order that makes sense to create the poem, “I Can’t Said the Ant” by Polly Cameron.

I Can't Said The Ant by Polly Cameron

I was taking a walk when I heard a loud clatter,I rushed into the kitchen to see what was the matter.There on the floor with the tea pouring outWas a cracked tea-pot with a broken spout.

WHAT COMES NEXT?

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Brain BreakWHEN IS YOUR BIRTHDAY?

Start with the number of the month you were born:

January – 1February – 2March – 3April – 4May – 5June – 6July – 7August – 8September – 9October – 10November – 11December – 12

Next, circle the day of the month you were born:

Enter the number of the month here:

1 2 3 4 5 6 7

8 9 10 11 12 13 14

15 16 17 18 19 20 21

22 23 24 25 26 27 28

29 30 31

Enter the day here:

If your total number is between:

2-15, move like a duck to the front of the room;

16-25, move like a dolphin to the back of the room;

26-43, move like a bird to the door side of the room.

Enter the TOTAL here:

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

AIR Self-Determination Scale ©

HOW TO FILL OUT THIS FORMPlease answer these questions about how you go about getting what you want or need. This may occur at school, or after school, or it could be related to your friends, your family, or a job or hobby you have.

This is not a Test.There are no right or wrong answers. The questions will help you learn aboutwhat you do well and where you may need help.

Goal - You may not be sure what some of the words in the questions mean. For example, the word goal is used a lot. A goal is something you want to get or achieve, either now or next week or in the distant future, like when you are an adult. You can have many different kinds of goals. You could have a goal that has to do with school (like getting a good grade on a test or graduating from high school). You could have a goal of saving money to buy something (a new iPod® or new sneakers), or doing better in sports (getting on the basketball team). Each person’s goals are different because each person has different things that they want or need or that they are good at.Plan - Another word that is used in some of the questions is plan. A plan is the way you decide to meet your goal, or the steps you need to take in order to get what you want or need. Like goals, you can have many different kinds of plans. An example of a plan to meet the goal of getting on the basketball team would be: to get better by shooting more baskets at home after school, to play basketball with friends on the weekend, to listen to the coach when the team practices, and to watch the pros play basketball on TV.

The AIR Self-Determination Scale was developed by the American Institutes for Research (AIR), in collaboration with Teachers College, Columbia University, with funding from the U.S. Department of Education, Office of Special Education Programs (OSEP), under Cooperative Agreement HO23J200005

HOW TO MARK YOUR ANSWERSEXAMPLE QUESTION:I check for errors after completing a project.EXAMPLE ANSWER:Circle the number of the answer which tells what you are most like:(Circle ONLY ONE number).

1 Never…………………………I never check for errors.2 Almost Never………………I almost never check for errors.3 Sometimes………………….I sometimes check for errors.4 Almost Always……………..I almost always check for errors.5 Always…………………………I always check for errors.

REMEMBERThere are NO right or wrong answers.

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THINGS I DO1. I know what I need, what I like, and what I’m good at.

2. I set goals to get what I want or need. I think about what I am good at when I do this.

Things I Do – Total Items 1 + 2

3. I figure out how to meet my goals. I make plans and decide what I should do.

4. I begin working on my plans to meet my goals as soon as possible.

Things I Do – Total Items 3 + 4

5. I check how I’m doing when I’m working on my plan. If I need to, I ask others what they think of how I’m doing.

6. If my plan doesn’t work, I try another one to meet my goals.

Things I Do – Total Items 5 + 6

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Check the box of the rating code which best describes you:(Check ONLY ONE box per question).

Please go on to the next page

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HOW I FEEL1. I feel good about what I like, what I want, and what I need to do.

2. I believe that I can set goals to get what I want.

How I feel – Total Items 1 + 2

3. I like to make plans to meet my goals.

4. I like to begin working on my plans right away.

How I feel – Total Items 3 + 4

5. I like to check on how well I’m doing in meeting my goals.

6. I am willing to try another way if it helps me to meet my goals.

How I feel – Total Items 5 + 6

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Check the box of the rating code which best describes you:(Check ONLY ONE box per question).

Please go on to the next page

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Check the box of the rating code which best describes you:(Check ONLY ONE box per question).

WHAT HAPPENS AT SCHOOL1. People at school listen to me when I talk about what I want, what I need, or whatI’m good at.

2. People at school let me know that I can set my own goals to get what I want or need.

How I feel – Total Items 1 + 2

3. At school, I have learned how to make plans to meet my goals and to feel good about them.

4. People at school encourage me to start working on my plans right away.

How I feel – Total Items 3 + 4

5. I have someone at school who can tell me if I am meeting my goals.

6. People at school understand when I have to change my plan to meet my goals. Theyoffer advice and encourage me when I’m doing this.

How I feel – Total Items 5 + 6

Please go on to the next page

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

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Check the box of the rating code which best describes you:(Check ONLY ONE box per question).

Please go on to the next page

WHAT HAPPENS AT HOME1. People at home listen to me when I talk about what I want, what I need, or whatI’m good at.

2. People at home let me know that I can set my own goals to get what I want or need.

How I feel – Total Items 1 + 2

3. At home, I have learned how to make plans to meet my goals and to feel good about them.

4. People at home encourage me to start working on my plans right away.

How I feel – Total Items 3 + 4

5. I have someone at home who can tell me if I am meeting my goals.

6. People at home understand when I have to change my plan to meet my goals. Theyoffer advice and encourage me when I’m doing this.

How I feel – Total Items 5 + 6

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

Never

1

Almost Never

2

Sometimes

3

Almost Always

4

Always

5

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Please go on to the next page

PLEASE WRITE YOUR ANWERS TO THE FOLLOWING QUESTIONS…

Give an example of a goal you are working on.________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_

What are you doing to reach this goal?________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_

How well are you doing in reaching this goal?________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_

MAHALO!

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My Cultural Background ScaleMy Cultural Background Scale

Check one box below to indicate how much you identify with that culture.

Write in the main ethnic group of your heritage: __________________

If there is another ethnic group you MOST identify with, write in: ________________

Check one box below to indicate how much you identify with that culture.

Check one box below to indicate how much you identify with “Local” culture.

Check one box below to indicate how much you identify with American (“Mainland”) culture.

Check one box below to indicate how much you identify with Native Hawaiian culture.

ALL PAU. MAHALO!

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Not at all  A little bit

  Moderately

A lot

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