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* Indicates required question
What is your first name and last name?
*
Your answer
What is your gender?
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Male
Female
Prefer not to say
Please leave your phone number and email address.
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Your answer
How long have you been in the U.S.?
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0-6 months
6-12 months
1-2 years
More than 2 years
What is your status in the U.S.?
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Refugee
Asylee
SIV (Special Immigrant Visa)
Green card
U.S. citizen
Other:
What country do you come from?
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Your answer
What is your native/first language?
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Your answer
How would you describe your level of English?
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I do not know any English at all
I only know the alphabet and can read a couple of words
Basic every day English to help me do the shopping
Beginning (I can read and write a little, and speak about simple things)
Intermediate (I can understand a lot of English and can express my ideas but I know I need to improve it)
High-intermediate (Overall, I am comfortable with English but can improve some things)
Advanced (In my country I used English for work with international organizations)
What is your educational goal here is the U.S.?
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I want to get a job and I need English skills to do it
I want to get a better job so I need to improve my English
I want to be comfortable talking to people in my community and at work but I am not planning to use English for academic purpose
I want to go to college and get a degree here
Other:
What is your education in your country?
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I cannot read or write in my first language
I completed elementary/primary school in my country
I graduated from high school in my country
I took some college/university classes in my country but I didn't finish
I have a Bachelor's Degree (4 years of university)
I have a Master's Degree
I have done post-graduate study in my country
Other:
What kind of help do you need at this time?
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English classes
Housing assistance
Transportation
Transition to the new culture
Computer skills
Financial assistance to access to internet/stationary/laptop
Other:
Required
Did you study English before? If yes, where? Describe the setting and how long you took classes. (Did you study at a school, with a private teacher or independently?) If you didn't study, skip this question.
Your answer
What is your preference for English classes? (Mark all choices that apply to you)
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in person
on my computer using Zoom
both in person and on Zoom
Required
What is the closest city to where you live now? (for example, Fairfax, Alexandria, Leesburg, Chantilly, Springfield...)
Your answer
Do you have a computer you can use at home? Do you have internet connection?
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Yes
No
Maybe
Other:
When can you take English classes? (Mark all choices that apply to you)
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mornings
day time (12- 5 pm)
evenings
Saturday
Sunday
Other:
Required
How would you describe your comfort level with computers?
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I cannot use a computer
I can use a computer/iPad a little
I am comfortable using computers and technology
I often show others how to solve computer problems
Expert: I can teach others how to use computers and various applications
Do you know how to use Zoom?
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Yes
No
Maybe
Please tell us about the work you did in your country? What was your job or jobs?
Your answer
Please feel free to share anything else we need to know about you.
Your answer
What questions do you have for us?
Your answer
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