Volunteer Information
*First Name *Last Name

Please enter any phone numbers if they've changed since your last quarterly report. Thank you.
(H) (W) (C)

Street Address 1
Street Address 2
City State Zip Code

*E-mail address

Placement Advisor Choose from the list of PAs below Jan Auerbach Elise Bruml Steve Cristofar Anne Jillson Ann Poad Tracy Tapscott

Has tutoring ended? Yes No
If yes, date ended?

Reason tutoring ended

If you are not presently tutoring, are you available to tutor? Yes No

Does the student need another tutor? Yes No

Would you like to be contacted to discuss other volunteer opportunities? Yes No

Student Information (if tutoring a group of non-LCNV students, please give location and number of students instead)
First Name
Last Name (or location of group)
Middle Initial (or number of students in group)

Please fill out if changed:
Home Tel. Work Tel.

Street Address 1
Street Address 2
City State Zip Code

I. VOLUNTEER HOURS

Total tutoring hours for this quarter
Tutor preparation and travel time
Trainer (include preparation & travel time)
Placement advisor/student interviewer
Workshop registration, in-service help
Board member
Other hours, please specify

II. BOOK LEVEL AT END OF QUARTER/HOMEWORK HOURS FOR THE QUARTER

Laubach Way to Reading
Level

Life Prints
Level

Survival English
Yes, I'm using Survival English.

Taking Off Literacy Workbook
Yes, I'm using the Taking Off Literacy Workbook.

Side by Side
Level

Side by Side Plus
Level

Other materials used:

Estimated hours student spent on homework during this quarter:

III. ENGLISH SKILLS
What skills in understanding, speaking, reading, and/or writing English did you work on this quarter? What progress did your student make in these areas? (e.g., worked on pronunciation, student can now hear difference between /r/ and /l/sounds).

IV. If your student was employed at the beginning of the quarter, is he/she still employed?    Yes No

V. Did your student get a job this quarter?   Yes No

VI. If your student is a citizen, did he/she register to vote or vote for the first time this quarter?   Yes No

VII. PERSONAL LEARNING GOALS/LIFE ACHIEVEMENTS
Please list any achievements your student made this quarter. Write each achievement on its own line under the most appropriate category. If a category is not appropriate for your student at this time, leave it blank. Mark the “Achieved” circle if the goal has been achieved. Mark the “Working on” circle if your student made progress toward that goal but didn’t completely achieve it. If you are unsure in which category to place an achievement, put it in the category which best fits your individual student’s learning goals. For example, if the student learned how to read a bus schedule in order to go to the doctor, enter “read a bus schedule” under the “Health” category. However, if the student did so to get to job interviews, place it under the “Entered Employment” category. Do not include achievements that occurred before tutoring began or if you have included them in previous quarterly reports unless your student accomplished them at a higher level this quarter – e.g. read a harder book, spoke to a child’s teacher about more complicated matters.

Looked for employment (e.g., filled out job application, read job ads):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Advanced employment (e.g., filled out work form, passed work-related test, got promoted):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Citizenship (e.g., submitted application for naturalization, passed citizenship test, voted):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Entered other education or training (e.g., enrolled in LCNV class, advanced into LCNV’s Basic program, participated in vocational training course):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Financial/consumer skills (e.g., made change, wrote check, asked for location of items in a store):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Increased involvement in child’s learning (e.g., read to a child, helped a child with homework, attended parent-teacher conference):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Family (e.g., planned a trip, participated in extracurricular activities):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Health (e.g., described ailments, read medicine label, filled out insurance form):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

Personal (e.g., chatted with neighbor, got a library card, read a book):
  Achieved   Working on
  Achieved   Working on
  Achieved   Working on

VIII. Has your student experienced any intangible improvements this quarter which might be connected to improved English (e.g., increased self-confidence)?

IX. Please share how tutoring has affected you or your student or any special comments or concerns you may have. Do you need additional materials? How can we assist you in your tutoring?