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Name

Status

Instance

Student (English Academic / Non English Academic /


senior/ junior/ elementary school)
Teachers
Employers
Parents
Others (_________________________________)

Part A
In what situation is English (or would English be) useful for you?
Please check the appropriate column

Put this sign in what situation would English be useful for you.
Num

Questionnaire

A1.

Buying ticket plane

A2.

Go to abroad

A3.

Watching Hollywood movies

A4.

Teaching or learning something in school

A5.

Communicating with friends

A6.

Buying something in Indomart

A7.

Guiding tourist in Tourism places

A8.

Listening music

A9.

Reading instruction in cosmetic product

Very
usefu
l

Usef
ul

Not
usefu
l

A10.

Visiting Bali

A11.

Reading the Jakarta Post

A12.

Chatting with foreigner in Yahoo Messenger

A13.

Singing a song

A14.

Reading your lesson

A15.

Asking friends studying together

A16.

Learning English in class

A17.

Speaking to your lecturer

A18.

Making passport

A19.

Taking vacation in Australia

A20.

Doing national examination

A21.

Continuing study in University

A22.

Doing Job interview

A23.

Receiving email

A24.

Knowing popular idol

A25.

Watching sport news in television

A26.

Connecting with facebook

A27.

Searching something in google

A28.

Using English with family members

A29.

Operating computer
Please Explain:

Other
s

Part B
From the list above please choose five that are the most important
for you. Write the number below

Part C
If you already speak English, please indicate your present level of
ability in English
C1. Basic (lower): very limited vocabulary, grammar, and pronunciation
heavily influenced by mother tongue.
C2. Basic (upper): wrong pronunciation, short conversation on a few
predictable topics; survival level knowledge of vocabulary, grammar, and
idiom
C3. Intermediate (lower): communicate with English fluently but different
topics, though still some difficulty with vocabulary, idiom, grammar and
pronunciation
C4. Intermediate (upper): can manage comfortably in familiar situations and
with familiar topics, though still some difficulty with vocabulary, idioms,
grammar, and pronunciation.
C5. Advanced: able to converse fluently and naturally on most topics; little
difficulty with vocabulary, idioms, grammar, and pronunciation.
Please put this sign in box that indicating your present level of ability in
English
C1. Basic (lower)
C2. Basic (upper)

C3. Intermediate
(lower)
C4. Intermediate
(upper)
C5. Advanced
C6. If you have studied English, please indicate under what circumstances.
a. I studied English in Formal education (elementary, junior high school,
senior high school and university)
b. I took English course
c. I studied with a private tutor
Other

C7. If you attended (English course, formal education and other), please
indicate the length and frequency of them.
Example:
Nu
m
1

Nu
m
1

Activities
Formal
education

Frequency

week
s

Activities
Formal
education

English course

A private tutor

Other

hour
s

per

week

Frequency
week
s

hour
s

per

wee
k

____________
____________

C8. How useful was the formal education? (Please circle your choice.)
Very useful

Somewhat useful

Not useful

C9. How useful was the English course? (Please circle your choice.)
Very useful

Somewhat useful

Not useful

C10. How useful was the private tutoring? (Please circle your choice.)
Very useful

Somewhat useful

Not useful

C11. How useful was the ..? (Please circle your choice.)
Very useful

Somewhat useful

Not useful

C12. If you have used one or more textbooks, please indicate the name of
each text and how are useful or otherwise it was:
Name of textbook
1 Metode cepat
menguasai bahasa
inggris
2 ______________________
3 ______________________
4 ______________________
5 ______________________

Very
usef
ul

useful

Not
usef
ul

C13. To what would you attribute your present level of ability in English?
Very
usef
ul

useful

Not
usef
ul

I attended a useful
course
I studied in formal
2
education
I studied with a private
3
tutor
1

4 I enjoy studying English


I need English for my job

Other
6 ________________________
C14. What activities or experiences were most helpful in your study of
English? Please elaborate.

Part D
If you have studied English before, but have since stopped studying
English, please complete part D below by checking the appropriate
box
I have studied English before, but I stopped because of the
following reason(s):
Situations
D1

I didnt have time to study English again

D2

I felt that I was not making any progress

Very
true

Somewh
at true

Not
true

D3
D4

There is no opportunities to use English in


outside the classroom
The lesson were not useful because:
a. Difficult to communicate with English
b. Pronunciation problem
c. Many vocabulary that difficult to
memorize

D5
D6
D7

The teacher did not know how to teach


English
I did not like the teaching methods used
The materials were:
a. Uninteresting
b. Irrelevant to my needs
c. Too easy
d. _________________________
e. _________________________

D8

Other:
_________________________________________
_________________________________________
_________________________________________

Part E
Have you ever used the following activities in studying English? If
you indicate yes, how useful were they?
Num

Activities

Very
useful

Useful

Not
useful

E1
E2
E3
E4
E5
E6
E7
E8
E9
E10
E11
E12

Practicing conversation from a book or


internet
Free conversation with native speakers
Free conversation with other learners of
English
Memorizing bilingual vocabulary lists.
Studying English textbook at boarding
house / home
Studying the grammar of English
Studying English Pronunciation
Using MP3 at boarding house / home
Speaking English without making
mistakes in grammar or pronunciation
Translating English text from newspaper
or others
Using dictionary
Asking friends to fix your pronunciation

Other:
_____________________________________________
_____________________________________________
_____________________________________________

Part F
In class or with a tutor, I would like my teacher to:
Nu
Activities
m
F1
Practice before explaining new grammar
points
F2

Correct my mistakes of grammar

No

A
little

Good

Best

F3

Correct my mistakes of diction

F4

Correct my mistakes of pronunciation

F5

Use Indonesian language and English

Part G
What are your feelings about English as a language?

Situations
G1

English is a language with a rich vocabulary

G2

English is a very difficult language

G3
G5

English is a language where pronunciation is very


important
English is a language with a lot of grammar

G6

English is a beautiful language

G7

English is a amazing language to learn

G8

English is a boring language to learn

Very
true

Somewh
at true

Not
true

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