Home Telephone Number Work Telephone Number

Street Address

City State Zip Code

E-mail address

What jurisdiction do you pay taxes in?
Arlington
Alexandria
Fairfax
Other (please specify)

Placement Advisor

Has tutoring ended?
Yes No

If you are not presently tutoring, are you available to tutor? Yes No

A. Total tutoring hours for this quarter

B. Nontutoring volunteer hours
1. Tutor preparation and travel time
2. Trainer (include preparation & travel time)
3. Placement advisor
4. Workshop registration, in-service help
5. Board member
6. Other hours, please specify
Total nontutoring hours (Add 1 through 6, section B)

C. Workshop, in-service and seminar attendance hours

Student Information
First Name Last Name

Group Name (if tutoring in a group) Number in group
Group location (include city and zip)

Home Telephone Number Work Telephone Number

Street Address

City State Zip Code

Jurisdiction
Arlington
Alexandria
Fairfax
Other (please specify)

Has tutoring ended?
Yes No

Reason tutoring ended

Does the student need another tutor?
Yes No

Progress this Quarter

Laubach Way to English
Skill Book Level Lesson number

LifePrints
Level Unit number

Other materials used

Additional comments (successes, concerns)

Improvement and Achievements (check any that apply)
Self confidence
Got a job
Job performance
Job advancement
Registered to vote
Acquired citizenship
Got a library card
Got a driver's license
Entered ESL class
Other (please specify)

Personal Learning Goals Completed This Quarter
Please select any new goals completed this quarter from the Personal Learning Goals List below. Feel free to add other unlisted goals that your student has achieved.
Choose from the goals below 1. Reply to request for personal information (name, address, phone number, social security number) 2. Read/write own name, address, phone number, social security number 3. Ask for and tell time 4. Read a calendar 5. Find name in telephone directory 6. Use the telephone 7. Phone 911 emergency 8. Record and write simple telephone message 9. Read and interpret food labels 10. Identify names and value of U.S. currency 11. Determine correct change for purchases 12. Describe ailments/symptoms 13. Read labels/directions on medicine bottles 14. Use map to find destination 15. Read traffic signs and street names 16. Ask for location of items in a store 17. Use bus/Metro schedule 18. Ride bus/Metro to destination 19. Read Bible or other religious material 20. Read newspaper or magazine article 21. Read a bill 22. Write money orders or checks 23. Get a driver's license 24. U.S Citizenship exam 25. Read to children 26. Help children with school work 27. Speak with school personnel 28. Read/write notes to/from child's school 29. Fill out a job application 30. Read work-related materials 31. Fill out work forms/reports 32. Pass a work-related test
Choose from the goals below 1. Reply to request for personal information (name, address, phone number, social security number) 2. Read/write own name, address, phone number, social security number 3. Ask for and tell time 4. Read a calendar 5. Find name in telephone directory 6. Use the telephone 7. Phone 911 emergency 8. Record and write simple telephone message 9. Read and interpret food labels 10. Identify names and value of U.S. currency 11. Determine correct change for purchases 12. Describe ailments/symptoms 13. Read labels/directions on medicine bottles 14. Use map to find destination 15. Read traffic signs and street names 16. Ask for location of items in a store 17. Use bus/Metro schedule 18. Ride bus/Metro to destination 19. Read Bible or other religious material 20. Read newspaper or magazine article 21. Read a bill 22. Write money orders or checks 23. Get a driver's license 24. U.S Citizenship exam 25. Read to children 26. Help children with school work 27. Speak with school personnel 28. Read/write notes to/from child's school 29. Fill out a job application 30. Read work-related materials 31. Fill out work forms/reports 32. Pass a work-related test
Choose from the goals below 1. Reply to request for personal information (name, address, phone number, social security number) 2. Read/write own name, address, phone number, social security number 3. Ask for and tell time 4. Read a calendar 5. Find name in telephone directory 6. Use the telephone 7. Phone 911 emergency 8. Record and write simple telephone message 9. Read and interpret food labels 10. Identify names and value of U.S. currency 11. Determine correct change for purchases 12. Describe ailments/symptoms 13. Read labels/directions on medicine bottles 14. Use map to find destination 15. Read traffic signs and street names 16. Ask for location of items in a store 17. Use bus/Metro schedule 18. Ride bus/Metro to destination 19. Read Bible or other religious material 20. Read newspaper or magazine article 21. Read a bill 22. Write money orders or checks 23. Get a driver's license 24. U.S Citizenship exam 25. Read to children 26. Help children with school work 27. Speak with school personnel 28. Read/write notes to/from child's school 29. Fill out a job application 30. Read work-related materials 31. Fill out work forms/reports 32. Pass a work-related test
Choose from the goals below 1. Reply to request for personal information (name, address, phone number, social security number) 2. Read/write own name, address, phone number, social security number 3. Ask for and tell time 4. Read a calendar 5. Find name in telephone directory 6. Use the telephone 7. Phone 911 emergency 8. Record and write simple telephone message 9. Read and interpret food labels 10. Identify names and value of U.S. currency 11. Determine correct change for purchases 12. Describe ailments/symptoms 13. Read labels/directions on medicine bottles 14. Use map to find destination 15. Read traffic signs and street names 16. Ask for location of items in a store 17. Use bus/Metro schedule 18. Ride bus/Metro to destination 19. Read Bible or other religious material 20. Read newspaper or magazine article 21. Read a bill 22. Write money orders or checks 23. Get a driver's license 24. U.S Citizenship exam 25. Read to children 26. Help children with school work 27. Speak with school personnel 28. Read/write notes to/from child's school 29. Fill out a job application 30. Read work-related materials 31. Fill out work forms/reports 32. Pass a work-related test

Basic Language Skills Progress

Comments on your student's reading, writing, speaking, and listening progress:

Student: What have I learned?

I usually speak or read English outside of my lessons:
Not at all
One hour a week or less
About two or three hours a week
Four or more hours a week