Student Report Survey

Student Report

Student Survey

• Please do NOT write your name on the survey. Do NOT identify yourself in any other way.

• You do not have to answer all of the survey questions, but we hope that you will.

• Please mark all of your answers on this survey. Mark only one answer unless told to “Mark All That Apply.”

• Please read each question and put an X in the box next to your answer.

Example 1

			Strongly Disagree	Disagree	Don’t Know	Agree	Strongly Agree
I enjoy learning Math			1	2	3	4	5

Example 2

			8 Years Old	9 Years Old	10 Years Old	11 Years Old
I am			8	9	10	11

Thank you for taking this survey!

 

Student Survey

Put an X in the box next to your answer. Mark only one answer for each statement. Remember, your answers are private and no one will know how you answered.

Mark one choice
1.	Are you female or male?	1 Female
		2 Male
2.	How old are you?
	 Years
3.	What is your date of birth?
	   MONTH DAY YEAR

Mark your agreement or disagreement with the following.								Strongly Agree
							Agree
The students in this school…						Don’t Know
					Disagree
				Strongly Disagree
4.	Are nice to each other			1	2	3	4	5
5.	Work together on things.			1	2	3	4	5
6.	Make new students feel welcome.			1	2	3	4	5
7.	Get along well together.			1	2	3	4	5
8.	Work out problems without fighting.			1	2	3	4	5
9.	Take good care of school property.			1	2	3	4	5
10.	Take responsibility for what they do.			1	2	3	4	5
11.	Respect their teachers.			1	2	3	4	5
12.	Think it’s important to be a good citizen.			1	2	3	4	5
13.	Treat one another fairly.			1	2	3	4	5
14.	Tell the truth.			1	2	3	4	5
15.	Are treated fairly by the adults in the school.			1	2	3	4	5
16.	Are expected to get along.			1	2	3	4	5

Mark your agreement or disagreement with the following.								Strongly Agree
							Agree
The students in this school…						Don’t Know
					Disagree
				Strongly Disagree
17.	Are expected to be kind and caring.			1	2	3	4	5
18.	Are expected to treat each other fairly.			1	2	3	4	5
19.	Are expected to obey the rules.			1	2	3	4	5
20.	Are expected to tell the truth.			1	2	3	4	5
21.	Are allowed to work together in classes.			1	2	3	4	5
22.	Plan things together with their teachers.			1	2	3	4	5
23.	Have a say in what goes on in their classes.			1	2	3	4	5
24.	Decide rules together with their teachers.			1	2	3	4	5
25.	Help plan what they do in school			1	2	3	4	5
I would…
26.	Help someone learn something.			1	2	3	4	5
27.	Cheer up someone who is feeling sad.			1	2	3	4	5
28.	Get help if I saw a person being picked on.			1	2	3	4	5
29.	Be a friend to someone who is being teased.			1	2	3	4	5
30.	Get help for someone who is hurt.			1	2	3	4	5
How much do you agree?
31.	I like myself the way I am.			1	2	3	4	5
32.	I am having trouble with my schoolwork.			1	2	3	4	5
33.	I wish I were different.			1	2	3	4	5
34.	I am a good student.			1	2	3	4	5
35.	Things often go wrong for me.			1	2	3	4	5
36.	I have trouble figuring things out in class.			1	2	3	4	5
37.	I like school.			1	2	3	4	5
38.	I have trouble when I have to figure out schoolwork by myself.			1	2	3	4	5
39.	I feel good about my schoolwork.			1	2	3	4	5

Below are some things that can happen to kids every day. Think about how YOU feel, or would feel when these things happen to you. Put an X in the box next to your answer. Mark only one answer for each statement. Remember, your answers are private and no one will know how you answered.

40.	When I’m mean to someone, I usually feel bad about it later. 1 Yes                               2 Sometimes                                3 No
41.	I’m happy when the teacher says my friend did a good job. 1 Yes                               2 Sometimes                                3 No
42.	I understand how other kids feel. 1 Yes                               2 Sometimes                                3 No
43.	Other people’s problems really bother me. 1 Yes                               2 Sometimes                                3 No
44.	I feel happy when my friend gets a good grade. 1 Yes                               2 Sometimes                                3 No
45.	When I see a kid who is upset it really bothers me. 1 Yes                               2 Sometimes                                3 No
46.	Its easy for me to tell when my mom or dad has a good day at work. 1 Yes                               2 Sometimes                                3 No
47.	It bothers me when my teacher doesn’t feel well. 1 Yes                               2 Sometimes                                3 No
48.	I feel sorry for kids who can’t find anyone to hang out with. 1 Yes                               2 Sometimes                                3 No
49.	Seeing a kid who is crying makes me feel like crying. 1 Yes                               2 Sometimes                                3 No
50.	When I see someone who is happy, I feel happy too. 1 Yes                               2 Sometimes                                3 No

Here are some statements about your school. For each one, use an X to tell us how much you agree or disagree with the statement. You should only mark one box for each statement.

51.	When I’m in class, I participate in class discussion. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
52.	I try hard to do well in school. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
53.	In class, I work as hard as I can. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
54.	I pay attention in class. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
55.	When I am in class, I listen very carefully. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
56.	When I’m in class, I just act like I’m working. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
57.	I don’t try very hard in school. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
58.	In class, I just do enough to get by. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
59.	When I’m in class, I think about other things.. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
60.	When I’m in class, my mind wanders. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT

Below are some things that kids do from time to time. How many times in the last two weeks has each happened to YOU. Put an X next to your answer. Mark only one answer for each statement. Remember, your answers are private and no one will see how you answered, not even your teacher.

61.	I teased a kid at school. 1 Never      2 Once or twice      3 A few times      4 Many times
62.	I was sent home from school for bad behavior. 1 Never      2 Once or twice      3 A few times      4 Many times
63.	I was loud or made so much noise at school that I got in trouble. 1 Never      2 Once or twice      3 A few times      4 Many times
64.	I pushed, shoved, or hit a kid from school. 1 Never      2 Once or twice      3 A few times      4 Many times
65.	I took things at school without paying for them, such as food in the lunchroom. 1 Never      2 Once or twice      3 A few times      4 Many times
66.	I called a kid at school a bad name. 1 Never      2 Once or twice      3 A few times      4 Many times
67.	I said that I would hit a kid at school. 1 Never      2 Once or twice      3 A few times      4 Many times
68.	I left out another kid on purpose. 1 Never      2 Once or twice      3 A few times      4 Many times
69.	I made up something about other students to make other kids not like them anymore. 1 Never      2 Once or twice      3 A few times      4 Many times
70.	I broke or ruined something on purpose that belonged to the school. 1 Never      2 Once or twice      3 A few times      4 Many times
71.	I took something from school from the teacher or other kids that did not belong to me. 1 Never      2 Once or twice      3 A few times      4 Many times
72.	I copied other students’ homework or copied off the other students’ tests. 1 Never      2 Once or twice      3 A few times      4 Many times
73.	I skipped school or didn’t go to class without an excuse. 1 Never      2 Once or twice      3 A few times      4 Many times

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