Multilevel Module Pilot Feedback Form 1.0

Feedback form

After you have piloted the module, please complete this feedback form.

Question Title

* 1. Are you currently (please check all that apply)

classroom teacher

Lead teacher

Administrator

Other (e.g. TESL Educator) Please specify

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* 2. Please identify which module you piloted or reviewed.

CLB 1-2: Reporting a Lost, Stolen or Damaged Bank card

CLB 3-4: At the Walk- in Clinic

CLB 5-6: Avoiding Scams and Fraud

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* 3. Please check:

I piloted some or all of the activities in the module in my classroom

I reviewed the module but did NOT pilot any of the activities

If you piloted the activities, please complete questions 3-14

If you reviewed only, please complete questions 8-14

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* 4. Which assessment tasks did you pilot? Choose all that apply.

Listening

Speaking

Reading

Writing

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* 5. Describe any modifications you made to the assessment tasks.

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* 6. How many of the skill-building and skill-using activities did you use? Choose one.

None

About 25 % of the activities

About 50% of the activities

About 70% of the activities

All

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* 7. Did you use additional resources? If so, please list them.

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* 8. How would you rate the usefulness of the materials, on a scale of 1 to 5?

	Not useful				Very useful
Module plan	Module plan Not useful	Module plan	Module plan	Module plan	Module plan Very useful
Assessment tasks	Assessment tasks Not useful	Assessment tasks	Assessment tasks	Assessment tasks	Assessment tasks Very useful
skill-using and skill-building activities	skill-using and skill-building activities Not useful	skill-using and skill-building activities	skill-using and skill-building activities	skill-using and skill-building activities	skill-using and skill-building activities Very useful

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* 9. What did you like best about the module?

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* 10. Do you have any suggestions for improvements or additions to the module? Please comment on content (e.g. any content that should be added or deleted), or format (e.g. ease of use).

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* 11. Do you have any suggestions for module topics that would be useful at this CLB level?

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* 12. Future modules will include support for ESL literacy learners. Do you have ESL literacy learners in your classes?

Yes

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* 13. What kinds of activities would help you support ESL literacy learners to complete this module?

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* 14. Future modules may include options for incorporating technology. What digital devices or platforms do you and learners have access to in your program?

Choose all that apply:

In class computers, laptops, tablets

Outside of classroom computers, laptops, tablets

Personal smartphones

Word processing software (e.g., Word, Google Docs)

Internet access

"Other"

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* 15. What percentage of learners have access to the following devices and/or internet in their home?

	0-25%	26-50%	51-75%	76-100%	I don't know
Computer or laptop	Computer or laptop 0-25%	Computer or laptop 26-50%	Computer or laptop 51-75%	Computer or laptop 76-100%	Computer or laptop I don't know
personal smart phone	personal smart phone 0-25%	personal smart phone 26-50%	personal smart phone 51-75%	personal smart phone 76-100%	personal smart phone I don't know
Internet access	Internet access 0-25%	Internet access 26-50%	Internet access 51-75%	Internet access 76-100%	Internet access I don't know

Question Title

* 1. Are you currently (please check all that apply)

Question Title

* 2. Please identify which module you piloted or reviewed.

Question Title

* 3. Please check:

Question Title

* 4. Which assessment tasks did you pilot? Choose all that apply.

Question Title

* 5. Describe any modifications you made to the assessment tasks.

Question Title

* 6. How many of the skill-building and skill-using activities did you use? Choose one.

Question Title

* 7. Did you use additional resources? If so, please list them.

Question Title

* 8. How would you rate the usefulness of the materials, on a scale of 1 to 5?

Question Title

* 9. What did you like best about the module?

Question Title

* 10. Do you have any suggestions for improvements or additions to the module? Please comment on content (e.g. any content that should be added or deleted), or format (e.g. ease of use).

Question Title

* 11. Do you have any suggestions for module topics that would be useful at this CLB level?

Question Title

* 12. Future modules will include support for ESL literacy learners. Do you have ESL literacy learners in your classes?

Question Title

* 13. What kinds of activities would help you support ESL literacy learners to complete this module?

Question Title

* 14. Future modules may include options for incorporating technology. What digital devices or platforms do you and learners have access to in your program? Choose all that apply:

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* 15. What percentage of learners have access to the following devices and/or internet in their home?

* 14. Future modules may include options for incorporating technology. What digital devices or platforms do you and learners have access to in your program?

Choose all that apply: