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Please enter your first and last name.
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Race
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White
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African American
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American Indian
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Asian & Pacific Islander
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Other, please specify
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Marital Status
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Single with no minor children
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Single with minor child/children
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Married with no minor children
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Married with minor child/children
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Divorced with no minor children
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Divorced with minor children
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| 5
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Age Range
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17 & under
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18 – 21
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22 – 25
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26 – 29
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30 – 33
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34 – 37
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38 – 41
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42 plus
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| 6
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My Educational Level is:
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Middle School
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GED or HSED
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Completed High School
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High School plus 1 – 2 years of college
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High School plus 3 - 4 years of college
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Associate Degree
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College degree
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Masters degree
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Master plus
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Other, please specify
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| 7
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My Mother's Educational Level is:
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Middle School
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GED or HSED
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Completed High School
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High School plus 1 – 2 years of college
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High School plus 3 - 4 years of college
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Associate Degree
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College degree
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Masters degree
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Master plus
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Ph. D or Doctorate Degree
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Other, please specify
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| 8
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My Father's Educational Level is:
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Middle School
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GED or HSED
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Completed High School
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High School plus 1 – 2 years of college
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High School plus 3 - 4 years of college
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Associate Degree
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College degree
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Masters degree
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Master plus
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Ph. D or Doctorate Degree
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Other, please specify
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| 9
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Select the statement that best describes your chemistry background
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Did not take chemistry in high school or at a college
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I took at least one semester of chemistry in high school.
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I took at least one semester of chemistry in high school and took a college level chemistry class at CVTC or another institution.
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I did not take chemistry in high school but took a college level chemistry class at CVTC or another institution.
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Considering high school chemistry
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I did not take high school chemistry.
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I completed high school chemistry and received an A for a final grade.
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I completed high school chemistry and received an A- for a final grade.
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I completed high school chemistry and received a B+ for a final grade.
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I completed high school chemistry and received a B for a final grade.
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I completed high school chemistry and received a B- for a final grade.
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I completed high school chemistry and received a C+ for a final grade.
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I completed high school chemistry and received a C for a final grade.
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I completed high school chemistry and received a C- for a final grade.
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I completed high school chemistry and received a D+ for a final grade.
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I completed high school chemistry and received a D for a final grade.
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I completed high school chemistry and received a D- for a final grade.
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I completed high school chemistry and received a F for a final grade
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| 11
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How long ago did you take high school chemistry
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I Did not take high school chemistry.
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0 – 1 years ago
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2 - 3 years ago
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4 – 5 years ago
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6 – 7 years ago
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8 - 9 years ago
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10 plus
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| 12
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Have you previously registered for this Elementary Chemistry class or Basic Chemistry at CVTC?
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no, this is my first attempt at this class
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yes, but withdrew so that a “W” is not on my transcript
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yes, but was unsuccessful in the course
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| 13
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If you are repeating this class because you did not successfully complete Elementary Chemistry or Basic Chemistry, how many times have you completed the class unsuccessfully in the past?
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none, this is my first attempt
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1
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2
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3
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| 14
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If you are repeating this Elementary Chemistry class because you did not successful complete Elementary Chemistry or Basic Chemistry, your grade in the LAST previously attempted class was?
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W (withdrew) W is on my transcript
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F
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D-
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D
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D+
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C-
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C
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C+
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B-
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| 15
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How many times have you completely withdrawn from all your classes for an entire semester at CVTC?
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zero this is my first semester (term)
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1
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2
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3
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4
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5 or more
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| 16
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How many times have you dropped a class at CVTC?
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zero this is my first semester (term)
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1
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2
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3
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4
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5 or more
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| 17
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Which if these CVTC campuses is closest to your home?
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Eau Claire Business Campus (W. Clairemont with walk over bridge)
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Chippewa Falls
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River Falls
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How far from the above campus location do you live?
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less than 5 miles
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5 – 15 miles
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16 – 25 miles
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26 – 35 miles
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36 – 45 miles
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46 – 55 miles
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56 – 65 miles
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66 plus miles
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| 19
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What type of Internet Connection do have at home?
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I do not have a computer at home None
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I have a computer but I do not connect to the internet
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Dial Up
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Cable Modem
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DSL
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Unknown
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How comfortable are you with computer technology?
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very comfortable
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comfortable
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not comfortable
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How much time do you spend on the Internet per WEEK at school?
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1 - 3 Hours
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4 - 6 Hours
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7 - 9 Hours
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10 - 12 Hours
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12 - 15 Hours
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16 plus Hours
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| 22
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How much time do you normally spend per WEEK on the internet at home?
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1 - 3 Hours
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4 - 6 Hours
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7 - 9 Hours
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10 - 12 Hours
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12 - 15 Hours
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16 plus Hours
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| 23
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The amount of time you anticipate spending per WEEK on this Elementary Chemistry Class?
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1 - 3 Hours
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4 - 6 Hours
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7 - 9 Hours
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10 - 12 Hours
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12 - 15 Hours
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16 plus Hours
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| 24
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During the semester, the amount of time you anticipate spending per WEEK for class related work for all your CVTC/College classes (Including this Elementary Chemistry Class)?
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1 - 3 Hours
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4 - 6 Hours
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7 - 9 Hours
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10 - 12 Hours
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12 - 15 Hours
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16 – 19 Hours
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20 - 23 Hours
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24 – 27 Hours
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28 - 31 Hours
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32 plus Hours
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| 25
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During the semester, the number of hours you anticipate working (employed) per WEEK while taking Elementary Chemistry class was?
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1 - 5 Hours
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6 - 10 Hours
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11 - 15 Hours
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16 - 20 Hours
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21 - 25 Hours
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26 - 30 Hours
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31 - 35 Hours
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36 – 40 Hours
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40 plus
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| 26
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During the semester, the number of hours per WEEK you anticipate spending playing video games?
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0
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1 - 3 Hours
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4 - 6 Hours
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7 - 9 Hours
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10 - 12 Hours
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12 - 15 Hours
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16 – 19 Hours
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20 - 23 Hours
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24 – 27 Hours
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28 - 31 Hours
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32 plus Hours
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| 27
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How many CVTC credits have you earned? Do not include any transfer credits from another college.
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zero this is my first semester (term)
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1 - 6
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7 - 12
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13 – 18
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19 – 25
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26 or more
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| 28
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How many credits have you completed at other colleges?
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zero
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1 - 6
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7 - 12
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13 – 18
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19 – 25
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26 or more
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| 29
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How many CVTC credits are you enrolled in this term?
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1 – 3 credits
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4 – 6 credits
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7 – 9 credits
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10 – 12 credits
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13 – 15 credits
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16 – 18 credits
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19 – 21 credits
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22 – 24 credits
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25 plus credits
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| 30
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Are you also taking credits at another college this term? If yes, how many?
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No I am not taking courses at another college
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Yes, 1-3 credits
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Yes, 4-6 credits
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Yes, 7-9 credits
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Yes, 10-12 credits
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Yes, 13-15 credits
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Yes, 16-18 credits
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Yes, 19-21 credits
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Yes, 22-24 credits
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Yes, 25 plus credits
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