Teacher Feedback Survey Page 9
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9These next questions are about you and your job. Please check or write in your best answer to each question.
1. What subject(s) do you primarily teach?
Health/Physical Education
Social Sciences
Language Arts
Arts/Theater/Music
Math/Computer Science
Natural Sciences
Guidance/School Counseling
Other: ___________________________
2. What is your average LST class size?
Students
3. How many years of classroom teaching experience do you have (including this year)?
Years
4. What is the highest degree you have attained?
High School/GED
Masters Degree/Masters+30
Associates Degree
Ed.S. (Educational Specialist)
Bachelors Degree
Ph.D./Ed.D.
Other: __________________________
5. What is your gender?
Male
Female
6. What is your race/ethnicity (check all that apply)?
White/Anglo, Caucasian
American Indian/Native American
Black/African American
Asian/Pacific Islander
Hispanic/Latino
Other: ______________________
7. What is your age?
20-29
50-59
30-39
60-69
40-49
70-79
Please provide your name, address and gift card preference below to ensure the $20 gift card is mailed directly to
you. Your personal information will be kept private and will never be associated with feedback data.
Target
Walmart
________________________________________________
If neither store is specified, a Target card
will be sent.
First & Last Name
____________________________________
______________________________
______________
Street Address
City, State
Zip Code
Thank you for completing the LifeSkills Training (LST) Teacher Feedback questionnaire. Your
comments are invaluable in our understanding of implementation successes and barriers. We
greatly appreciate your time and attention.
Please return completed form to:
Joan Bryant or Diane Ballard, Blueprints Project Manager
Center for the Study and Prevention of Violence
483 UCB, Boulder, CO 80309
joan.bryant@colorado.edu
or
diane.ballard@colorado.edu
303-735-0455 or 303-735-4164 | 303-492-2151 Fax
11/13/14
Page 8
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