I used this survey when teaching Lucy Calkins Units of Study in 2nd Grade. In the last Unit, "Series Book Clubs", students form Book Clubs. where they focus on different reading skills. I used this survey to group students into an area where they needed more instruction.
I started by introducing book clubs to the students. I reviewed the three options given with examples. I asked them to think, "which one could I use a little more help with?" I handed out the surveys and had them rate how they felt about each one. That night I looked over the surveys and grouped them based on their needs/my knowledge and observations.
In addition to the survey, there are 3 book club signs and club tips. I hung the signs from the ceiling above the tables/meeting spots of each club. I provided students with the list of tips to keep them on track as I circulated to each group.