Form O Survey

OMB #: 0925-0542

Expiration Date: 4-30-08

Form O

Brain Power! Challenge Program

Middle Grades 6–9

Survey for Control Group Teachers

As part of your agreement to participate as a teacher in the control group of the Brain Power! Challenge curriculum intervention, please take a few minutes to fill out this brief questionnaire. Thank you.

This section includes questions about your background and experience.

1. Including this year, how long have you been teaching? (Please circle one response for each item.)

Number of years	0–5 years	6–11 years	12–17 years	18–23 years	24 years or more
a. Teaching	1	2	3	4	5
b. Teaching current grade	1	2	3	4	5
c. Teaching at this school	1	2	3	4	5

2. Have you ever used the Brain Power! curriculum or Brain Power! Challenge curriculum in any of the following grades during the last 5 years of your teaching career (or during your entire teaching career, if less than 5 years)? (Please circle one response for each item.)

Yes No

a. Kindergarten 1 2

b. First grade 1 2

c. Second grade 1 2

d. Third grade 1 2

e. Fourth grade 1 2

f. Fifth grade 1 2

g. Sixth grade 1 2

h. Seventh grade 1 2

i. Eighth grade 1 2

j. Ninth grade 1 2

3. What is your teaching credential status? (Please circle one.)

Regular or standard credential 1

Temporary certificate, provisional internship permit, or emergency
permit (requires additional coursework before regular certification
can be obtained) 2

Probationary credential (initial certification issued after satisfying all requirements except completion of the probationary period) 3

Not credentialed 4 (Skip to Question 5)

4. In what area(s) does your credential certify you to teach? (Please circle all that apply.)

a. Elementary education 1

b. Early childhood education 2

c. Secondary or middle education 3

d. Science 4

e. Health 5

f. Mathematics 6

g. History or Social Studies 7

h. Arts or Music 8

i. Reading 9

j. Special education 10

k. Bilingual education 11

l. Other (please specify) 12

5. Are you:

Male? 1

Female? 2

6. What is your age? (Please circle one.)

Less than 25 1

25–35 2

36–45 3

46–55 4

56–65 5

65 or older 6

7. What is the highest degree you’ve received? (Please circle one.)

Bachelor’s degree 1

Bachelor’s degree plus additional graduate course credit(s) 2

Master’s degree 3

Master’s degree plus additional graduate course credit(s) 4

Professional degree 5

This section includes questions about your classroom instruction and about your existing knowledge of neurobiology.

8. Have you taught or do you plan to teach the following topics during this school year (2006–2007)? (Please circle one on each line.)

Topic	No, have not taught and do not plan to teach	Yes, have already taught	Yes, plan to teach later
a. The five major parts of the brain and their functions	1	2	3
b. Nerve cell communication (neurotransmission)
c. How stimulants like caffeine, nicotine, and Ritalin affect the brain and body	1	2	3
d. How alcohol, marijuana, and inhalants affect the brain and body	1	2	3
e. How heroin and cocaine affects the brain and body	1	2	3
f. How methamphetamine, steroids, and common club drugs affect the brain and body	1	2	3
g. How drugs are presented in the media	1	2	3
h. The short and long-term effects of marijuana use	1	2	3
i. Definition of addiction and how it affects the brain	1	2	3
j. How prescription drugs affect brain functioning when not used properly	1	2	3

9. If you answered Yes to any of the topics in Question 9 a–j, approximately how much time did

you spend (or do you plan to spend) teaching each over the course of this school year? (Please circle one.)

1–3 hours 1

4–6 hours 2

7–8 hours 3

More than 8 hours 4

10. How would you rate your current knowledge in each of the following topics? (Circle one on each line.)

Topic	Modest or very little amount	Fair or moderate amount	Significant or sizable amount
a. Names of major regions of the brain	1	2	3
b. Specific responsibilities of each brain region
c. The parts of a neuron and their individual functions	1	2	3
d. The process of neurotransmission	1	2	3
e. The role of neurotransmitters	1	2	3
f. The effects of prescription drugs on the brain and body when not used properly	1	2	3
g. The effects of cocaine and heroin on the brain and body	1	2	3
h. The effects of alcohol on the brain and body	1	2	3
i. The effects of marijuana on the brain and body	1	2	3
j. The effects of inhalants on the brain and body	1	2	3
k. The effects of methamphetamine, steroids, and club drugs on the brain and body	1	2	3
l. How addiction affects the brain	1	2	3

THANK YOU!

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