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* 1. My gender is:

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* 2. My age is: 

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* 3. My race or ethnicity is: 

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* 4. My occupation is: 

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* 5. Number of children in this school district:

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* 6. My child/children attend _____ School.

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* 7. My child receives special education services at  school (IEP, 504 plan):

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* 8. My child receives English-language learning support at school.

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* 9. School facilities (buildings, grounds) are adequate.

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* 10. The school maintains a pleasant learning environment.

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* 11. The school is a safe environment.

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* 12. Riding the bus is safe for students.

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* 13. Students are treated fairly by teachers and administrators.

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* 14. I am satisfied with the level of parent involvement at the school.

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* 15. Communication (amount and information) from the school district is adequate.

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* 16. Communication (amount and information) from the school is adequate.

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* 17. Communication (amount and information) from the teachers is adequate.

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* 18. I can easily communicate with my child’s teacher(s).

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* 19. I can easily communicate with my child’s principal.

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* 20. I am satisfied with the curriculum (what my child studies and learns).

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* 21. Homework assignments are meaningful.

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* 22. The amount of time spent on homework is appropriate.

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* 23. Teachers meet the needs of individual students.

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* 24. My child is a (an) _____ reader.

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* 25. My child is a (an) _____ writer.

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* 26. My child reads at home in order to complete school assignments.

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* 27. My child has lists of words that he/she studies at home for school assignments.

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* 28. My child writes original pieces for school assignments (sentences, paragraphs, stories, essays, etc.).

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* 29. I am _____ with the library/media center.

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* 30. I am _____ with the art program.

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* 31. I am _____ with the music program.

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* 32. I am _____ with the physical education program.

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* 33. I am _____ with guidance counseling services.

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* 34. I am _____ with remediation/intervention services.

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* 35. I am _____ with extracurricular activities (sports, clubs, etc.).

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* 36. My child’s favorite subject/class is _____.

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* 37. What else would you like for us to know?

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