Consultant Questionnaire

Please note: This questionnaire is not an application for ACT employment. The information requested is gathered in order to help ensure appropriate expertise and demographic composition among freelance item writers, soundness consultants, and fairness reviewers as required in ACT's work on resident and contract programs.

Fields marked with an asterisk (*) are required. This form is encrypted for the security of your personal information.

Check here if you would also be interested in item writing work.

1. Name
First Name*
Last Name*
Middle Initial
Title
3. Gender*	Female Male
4. Date of Birth (dd/month/yyyy) (e.g., 20 March 1950)	/ /
5. Racial/Ethnic Background
Specify If Other
6. How would you characterize your major employment?*
Specify If Other

Please answer Question 7 only if you are a present or former teacher or curriculum coordinator. If not, please skip to Item 8.

7A. Are you currently teaching?

7B. What is the total number of years you have taught?

7C. Are you currently a curriculum coordinator?

7D. Please complete the table and Sections E–H.

	Current or Most Recent Responsibilities
	Subject Area(s)	Grade Level(s)	Numbers of Years at Level
1.
2.
3.
4.
5.

7E. What is the approximate total number of students at the institution at which you currently work or most recently worked?

7F. What is the primary source of school funding at the institution at which you currently work or most recently worked?

7G. What is the racial/ethnic background of the majority of the students at the institution at which you currently work or most recently worked?

Specify If Other

7H. What is the location of the school at which you currently work or most recently worked?

8. Test Preparation Experience
A. Are you currently involved in school-sponsored test preparation activities?*

B. Are you currently a paid instructor in a commercial test preparation course?*

If "Yes" to Question B, please indicate the name of the course and course sponsor.

9. Do you write for other testing programs?*

If "Yes," please list them here.

10. Please complete the following table for all your postsecondary degrees.*

Degree	Subject Area(s)	Year Awarded	Institution	City & State

11. Date Questionnaire Completed (dd/month/yyyy) / / (e.g., 20/12/2000)
12. Preferred Mailing Address	Home Work
Institution (if work address)
Department (if work address)
Street Address*
City*
State*
ZIP*
Country
Phone*
Fax
Email
13. Alternate Address	Home Work
Institution (if work address)
Department (if work address)
Street Address
City
State
ZIP
Country
Phone
Fax
Email

14. Availability A. I would be interested in developing materials for the following test(s):
English Test	Reading Test	Mathematics Test	Science Test
B. The best time(s) of year to contact me to develop materials is/are:
Spring	Summer	Fall	Winter

15. References In the fields below, please list three professional references. If you are a secondary educator, one of these references must be your department chair or principal. A. Reference No. 1
Name (first, M.I., last)*
Institution
Department
Street Address*
City*
State*
ZIP*
Country
Phone*
Relationship to You* (e.g., principal, department chair, current employer)
B. Reference No. 2
Name (first, M.I., last)*
Institution
Department
Street Address*
City*
State*
ZIP*
Country
Phone
Relationship to You* (e.g., principal, department chair, current employer)
C. Reference No. 3
Name (first, M.I., last)*
Institution
Department
Street Address*
City*
State*
ZIP*
Country
Phone*
Relationship to You* (e.g., principal, department chair, current employer)

16. If you have any questions or comments about the form or about working with ACT as an item writer, please indicate them here.