Form Test Volunteer Information (Always complete this section.) *Last Name *First Name Middle Initial *E-Mail Address Please fill out if changed: Home Phone Work Phone Ext. Cell Address City State ZIP Code Volunteer Hours (Always complete this section with all of your hours for this quarter even if 0.) Total tutoring hours for this quarter Tutor preparation and travel time Trainer (training time including preparation and travel time) Student Interviewer/Assessment Specialist (include preparation & travel time) Others hours (workshop registrar, special events, etc.) Please specify roles for other hours Student Information *Last Name *First Name If your student’s contact information or address has changed, please inform firstname.lastname@example.org Tutoring Model (Check all that apply): One-to-one tutoring Two LCNV tutors team-teaching the same student Small group tutoring (2 to 4 learners) Tutoring to support an LCNV classroom Tutoring Continuation or Termination: *Has tutoring ended ? Yes No End of Match (Fill out this section only if tutoring ended. Otherwise leave blank and go to next page.) Date match ended: Who ended the tutoring? Student Tutor Other What are the primary reasons for termination: (Choose all that apply under student or tutor) Student-related Reasons Tutor-related Reasons Finished goals Completed commitment Entered another program Schedule conflict Tested out Health reasons Schedule conflict with job Moved Schedule conflict with family No place to meet Health reasons Student motivation or attendance Moved Incompatible No place to meet Transportation Inaccessible DK / other Incompatible Transportation DK / other Did the student achieve one or more goals during this match? Yes No Where will the student continue his/her education? (Only Answer if match-ended, mark all that apply) Another LCNV program (Which program?) Another agency’s program (Which program?) Student will not continue education at this time Don’t know *Book Level/Homework Hours At End Of Quarter Laubach Way to English Level Survival English/Taking Off Literacy Workbook Level Life Prints Level Standout Grammar Level Side by Side Level Oxford Picture Dictionary Level Side by Side Plus Level None of the above Other materials used:(Write in) *Homework Hours At End of This Quarter ACHIEVEMENT OF PERSONAL LEARNING GOALS Check off the most appropriate goal categories for the achievements your student made this quarter. (Check all that apply). Once you check a goal, a comments box will appear. Please feel free to write an explanation in the box. Employment Goals Improved job skills this quarter Started new employment this quarter Retained employment this quarter Got a promotion or a better job this quarter Comments Citizenship Goals Achieved citizenship skills this quarter Passed citizenship test this quarter Became a citizen this quarter Registered to vote or voted this quarter Comments Specialized Training Goals Received other education or training this quarter Improved technology skills this quarter Obtained drivers license this quarter Comments Health, Wellness, and Lifestyle Goals Improved communication or literacy in these areas this quarter Improved ability to navigate systems in these areas this quarter Comments Financial / Consumer Goals Improved communication or literacy in these areas this quarter Improved ability to navigate systems in these areas this quarter Comments Strengthened-the-Family Goals Improved communication or literacy in these areas this quarter Improved ability to navigate systems in these areas this quarter Comments Children’s Educational Goals Improved involvement in children’s education at home this quarter Improved ability to navigate school system this quarter Comments Community Involvement Improved communication or literacy in these areas this quarter Improved ability to navigate systems in these areas this quarter Engaged in community activities this quarter Comments Personal/ Intangible Goals My student experienced intangible improvements that may be connected to improved English this quarter Improved communication or literacy in these areas this quarter Comments STUDENT ATTENDANCE Number of tutoring sessions student cancelled this quarter: NOTES Use this section to describe what you are working on with your student or to relay any anecdotes you wish to share. (Please do not use this section to ask questions of staff; instead use the contact information below). CONTACT INFORMATION FOR CURRENT NEEDS If your student needs another tutor or you need another student, please contact your PA or email@example.com. To discuss other volunteer opportunities contact firstname.lastname@example.org. To order books or a library book, contact email@example.com. To discuss a problem or question that you have already discussed with your PA, contact firstname.lastname@example.org. To ask the part-time volunteer librarian a question, contact email@example.com. To see the library collection,click here THANK YOU FOR YOUR HELP! If your report is finished, please click the "Submit your report" button.