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Sample: Online Student Information Form
Instructions: Please complete the information below to help me understand more about you and your individual learning needs. Required questions are marked with an asterisk (*).

Created and shared by Michelle Pacansky-Brock.
http://www.teachingwithoutwalls.com

[Note: This survey plays an important role in scaffolding the use of emerging technologies into the teaching of an online class. It ensures students understand and agree to conditions and groundrules shared in the syllabus, provides the instructor with an online learning and technology demographics of the students, gives students an opportunity to communicate accommodations needed for disabilities, and assists the instructor with identifying high risk students through the open ended, "How are you feeling about this class?" question.]

First Name *
Your answer
Last Name *
Your answer
I have read and agree to the "Conditions of Participation" section of the the course syllabus. *
If you select "No," I will contact you directly to discuss your concerns.
I have read and agree to abide to the "Community Groundrules" included in the course syllabus. *
If you select "No," I will contact you directly to discuss your concerns.
Before this class, how many online classes have you successfully completed? *
Check all that describe you. *
Required
I have access to a computer with a microphone or webcam that I can use for this class. *
Do you have an iPhone, iPad, or iPod Touch? *
If so, you can use the free VoiceThread app!
How comfortable are you with experimenting with new technologies? *
not comfortable
very comfortable
Which type of learning environment is more appealing to you? *
Student-centered learning encourages students to create, collaborate, and contribute. Teacher-centered learning requires students to memorize and recite information.
Student-Centered
Teacher-Centered
You will be required to leave voice or webcam comments in this class. Which of the following methods will you use to do so? *
How do you feel about the idea of sharing your ideas through voice comments in our class VoiceThreads? *
Which of the following describes your experience with VoiceThread? *
In one word, describe how you are feeling about this class.
Your answer
In your opinion, what is the most important quality of an excellent online instructor?
Your answer
If you have a certified learning or physical disability that requires an accommodation, please let me know here. This is a private exchange.
Your answer
Is there anything you'd like to share with me at this point?
Your answer
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