Name :
Status : Student (English Academic / Non English Academic / senior/ junior/
elementary school)
Teachers
Employers
Parents
Others (_________________________________)
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.
Very Not
Num Questionnaire Useful
useful useful
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
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:
Others
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:
Num Activities Frequency
1 Formal education
6 weeks 3 hours per 1 week
Num Activities Frequency
1 Formal education
weeks hours per week
2 English course
3 A private tutor
4 Other
____________
____________
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:
Very useful Not
Name of textbook
useful useful
1 Metode cepat menguasai
√
bahasa inggris
2 ______________________
3 ______________________
4 ______________________
5 ______________________
C13. To what would you attribute your present level of ability in English?
Very useful Not
useful useful
1 I attended a useful course
2 I studied in formal education
3 I studied with a private tutor
4 I enjoy studying English
I need English for my job
5
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):
Very Somewhat Not
Situations
true true true
D1 I didn’t have time to study English again
D2 I felt that I was not making any progress
D3 There is no opportunities to use English in outside the
classroom
D4 The lesson were not useful because:
a. Difficult to communicate with English
b. Pronunciation problem
c. Many vocabulary that difficult to memorize
D5 The teacher did not know how to teach English
D6 I did not like the teaching methods used
D7 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?
Activities Very Useful Not
Num useful useful
Practicing conversation from a book or internet
E1
Free conversation with native speakers
E2
Free conversation with other learners of English
E3
Memorizing bilingual vocabulary lists.
E4
Studying English textbook at boarding house /
E5
home
Studying the grammar of English
E6
Studying English Pronunciation
E7
Using MP3 at boarding house / home
E8
Speaking English without making mistakes in
E9
grammar or pronunciation
Translating English text from newspaper or others
E10
Using dictionary
E11
Asking friends to fix your pronunciation
E12
Other:
_____________________________________________
_____________________________________________
_____________________________________________
Part F
In class or with a tutor, I would like my teacher to:
A
Num Activities No Good Best
little
F1 Practice before explaining new grammar points
F2 Correct my mistakes of grammar
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?
Very Somewhat Not
Situations
true true true
G1 English is a language with a rich vocabulary
G2 English is a very difficult language
G3 English is a language where pronunciation is very
important
G5 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
Feedback – Ms. Harmeet
5-10 sentences..
Your name (Full name)