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LEARN
ABOUT
YOU
Complete the Questionnaire
Wits Pilot Project | Questionnaire
Step
1
of
6
16%
Information Form
Xchange Community Learning — please complete all sections below.
Name and Surname
(Required)
First
Last
Student number
(Required)
ID / Passport No.
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Physical Address
(Required)
Postal Code
(Required)
Province
(Required)
Cell No.
(Required)
E-mail Address
(Required)
Race
(Required)
Gender
(Required)
Please tick appropriate box (marital status)
(Required)
Married
Divorced
Single
Home language
(Required)
Language of education
(Required)
Are you comfortable to correspond with us in English?
(Required)
Yes
No
If no, please provide further details
(Required)
Number of children
(Required)
What is your passion?
(Required)
Tick the one you thrive in
(Required)
Designing
Systems
People
Personality descriptors
Group 1 — Select ONE description that best describes you
(Required)
DOER: Good at routine physical tasks and details, consistent and reliable
SHAPER: Inventive, doing new ways to do things, visionary planner
HELPER: Good at meeting needs that involve people, like to please, avoids conflict
MOVER: Good at seeing what might be done with/by/for people, motivate people
(Adapted from Clarkson)
Group 2 — Select ONE description that best describes you
(Required)
STRUCTURED: in the same orderly way
INDEPENDENT: can do a lot of things on their own
NURTURING: like to take care of people
ACTIVE: always busy with some activity
(Adapted from Dunn and Dunn)
Group 3 — Select ONE description that best describes you
(Required)
Hardworking, conventional, accurate, stable, dependable, consistent, factual, organised
Analytic, objective, knowledgeable, thorough, structured, logical, deliberate, systematic
Sensitive, compassionate, imaginative, idealistic, sentimental, spontaneous, flexible
Quick, initiative, curious, realistic, creative, innovative, instinctive, adventurous
(Adapted from Tobias)
Group 4 — Select ONE description that best describes you
(Required)
Loyal, stable, patient, reliable, protective, calm
Attention to detail, careful, analytical, accurate, reserved
Relational, influencing, emotional, talkative, spontaneous, sensitive
Daring, assertive, direct, self-confident, competitive, quick
(Adapted from DISC)
Group 5 — Select ONE description that best describes you
(Required)
Organised, structured, traditional, step by step, stability, security
Focussed, precision, factual, critical, objective, accurate
Sensitive, teamwork, supportive, feelings, people orientated, body language
Investigative, strategic, imaginative, ideas, artistic, unstructured
(Adapted from Neethling)
Modality check
Select ALL the statements that best describe your preferences. (Adapted from Tobias)
Auditory
I need to hear myself say it in order to remember it
I often need to talk through a problem aloud in order to solve it
I memorize best by repeating the information aloud to myself over and over
I remember best when information fits into a rhythmic or musical pattern
I would rather listen to a recording of a book than sit and read it
Visual
I need to see an illustration of what I'm being taught before I understand it
I am drawn to flashy, colourful, visually stimulating objects
I almost always prefer books that include pictures or illustrations with the text
I look like I'm “daydreaming” when I'm trying to get a mental picture of what's being said
I usually remember better when I can actually see the person who's talking
Kinaesthetic
I have difficulty in sitting still for more than a few minutes at a time
I usually learn best by physically participating in a task
I almost always have some part of my body in motion
I prefer to read books or hear stories that are full of action
I remember best when I can do something with the information
Your biggest need at present
(Required)
Your biggest frustration at present
(Required)
Photo
Photo of yourself
(Required)
Accepted file types: jpg, jpeg, png, gif, heic, Max. file size: 32 MB.
Please upload a professional headshot or a clear, forward-facing photo of your face only.
Talent Form
Please complete this talent form by checking the boxes next to the skills that apply to you.
People-Oriented
Helping
Empathising
Communicating
Convincing
Teaching
Solving Problems
Leading
Managing/Undertaking
Counselling/Advising
Mediating
Caring
Information-Oriented
Structuring
Logical Reasoning
Calculating
Researching
Improving/Developing
Evaluating
Organising
Strategic Thinking
Conceptualising
Integrating
Administrating
Material/Mechanically-Oriented
Operating Machinery
Electronics/Technical Engineering
Computing
Conducting Precision Work
Building/Handcrafting
Painting
Decorating
Cooking/Baking
Gardening/Working Agriculturally
Working with Animals
Repairing
Creativity-Oriented
Acting
Dancing
Playing Sport
Music
Drawing
Designing
Sculpting
Creative Thinking
Writing
Photography
Entertaining/Amusing
Career Development Plan
What are your long-term career goals?
(Required)
What are your short-term career goals?
(Required)
What skills and competencies would you like to develop in the next 1-2 years?
(Required)
What professional development opportunities would you be interested in pursuing? (Select all that apply)
(Required)
On-the-job training
Workshops and seminars
Online courses
Mentorship programs
Leadership development programs
Other
How do you prefer to learn new skills and knowledge? (Select all that apply)
(Required)
On-the-job training
Workshops and seminars
Online courses
Mentorship programs
Leadership development programs
Other
Is there anything else you would like to share about your career development needs or aspirations?
Do you feel that you have the support and resources you need to achieve your career goals?
(Required)
Yes
No
I am not sure
Application for Assistance
Information required for statistical purposes
I live in a...
(Required)
Rural / farm area
Small town
Large town
City
Education
(Required)
No Matric
Matric
Diploma
Degree
Post Graduate degree
Masters
Doctorate
Degree Description
Degree Date
DD slash MM slash YYYY
Other studies
Other studies Date
DD slash MM slash YYYY
I could not succeed in my studies (tick all that apply)
(Required)
Financial strain
Workload balance
Academic malalignment
Family expectation
Mental health struggles
Wrong program choice
Poor time management
Under preparedness
Tuition fees
Lack of support
Living expenses
Neurodiversity gaps
Low level of participation in class
Loss of motivation
Summarise the facts, dates, times and places relevant to your need for assistance. For example poor passing rates, medical reports, any proof - of disadvantaged situations.
(Required)
Attach copies (not originals) of supporting documents.
Doc 1
Max. file size: 32 MB.
Doc 2
Max. file size: 32 MB.
Doc 3
Max. file size: 32 MB.
Consent Notice. How we use your information
(Required)
As part of the Xchange Community Learning and Wits University collaboration, we will collect personal information from you, including your contact details, academic background, and the results of your Persolog behavioural profile.
This information will be used to assess your learning needs and provide appropriate academic support. It may be shared between Xchange Community Learning, its affiliates, and the University of the Witwatersrand (Wits University) solely for this purpose.
Your information will be handled in accordance with the Protection of Personal Information Act, 2013 (POPIA). You may withdraw your consent at any time by contacting us at [contact email/number].
By ticking the box below, you confirm that you have read and understood the above, and that you consent to the collection, use, and sharing of your information as described.
I consent to the collection and use of my personal information as described above.
