Source: South Temiskaming Assessment & Referral Centre (Literacy Network Northeast). Adapted and used with permission.
| Personal Information |
|
| Name: ___________________ |
Date: ___________________ |
| Address: _________________ |
Interviewer: ______________ |
| |
|
| Phone: ___________________ |
Phone #2:_______________ |
| E-Mail:___________________ |
|
| Birthdate:_________________ |
Gender: M  F |
| First Language:____________ |
Other:__________________ |
| Source of Income:__________ |
|
| Who referred you?:_________ |
|
| Work Experience |
|
| Are you looking for work?____ |
|
If yes, what kind of work are you looking for?
__________________________________________________________ |
What reading and writing skills do you think you will need for this type of work?
__________________________________________________________ |
What other skills do you think you will need?
__________________________________________________________ |
Have you had a job before?
__________________________________________________________ |
If yes, what type of work did you do?
__________________________________________________________ |
Were reading and writing important when you were at work?
If yes, please explain.
__________________________________________________________ |
What was your favourite job and why?
__________________________________________________________ |
| School Experience |
Where did you go to school?
__________________________________________________________ |
What was the last grade you completed?
__________________________________________________________ |
How old were you when you left school?
__________________________________________________________ |
What language did you study in?
__________________________________________________________ |
What courses did you take?
__________________________________________________________ |
What was the best part about school?
__________________________________________________________ |
What was the worst part about school?
__________________________________________________________ |
Why did you leave school?
__________________________________________________________ |
Have you taken any other training or educational programs?
If yes, please tell me about them.
__________________________________________________________ |
Why are you interested in coming back to school now?
__________________________________________________________ |
| Family/Social |
Does anyone else in your family have trouble with reading or writing? Please explain.
__________________________________________________________ |
What kind of reading material do you have at home?
__________________________________________________________ |
What do you like to read?
__________________________________________________________ |
What do you like to do in your spare time?
__________________________________________________________ |
| Other |
Do you prefer to learn on your own or in a group?
__________________________________________________________ |
What time of day is best for you to come to school?
__________________________________________________________ |
What days of the week are best for you to come to school?
__________________________________________________________ |
Do you have anything else to add?
__________________________________________________________ |
