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Status
Instance
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.
A2.
Go to abroad
A3.
A4.
A5.
A6.
A7.
A8.
Listening music
A9.
Very
usefu
l
Usef
ul
Not
usefu
l
A10.
Visiting Bali
A11.
A12.
A13.
Singing a song
A14.
A15.
A16.
A17.
A18.
Making passport
A19.
A20.
A21.
A22.
A23.
Receiving email
A24.
A25.
A26.
A27.
A28.
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
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
D2
Very
true
Somewh
at true
Not
true
D3
D4
D5
D6
D7
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
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
No
A
little
Good
Best
F3
F4
F5
Part G
What are your feelings about English as a language?
Situations
G1
G2
G3
G5
G6
G7
G8
Very
true
Somewh
at true
Not
true