Student Survey

Attachment A
Student Survey

Student Survey

Instructions
Please answer some questions about your school and things that happen at your school. All the
answers you give to these questions will be confidential. This means we will not tell your
parents, your teachers, your school, or anyone else you know about what you tell us. We will not
ask you to put your name on the answer sheet.
You do not have to answer these questions and you can stop answering the questions any time
you want. If you don’t understand a question, please raise your hand.
Use the separate answer sheet to mark your responses. Mark only one response per question
unless a question tells you to do otherwise. To change an answer, please erase it completely.
When you are done, follow the instructions of the person giving you the survey.
Thank you for answering these questions. DO NOT write your name anywhere on the survey or
answer sheet.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless such collection displays a valid OMB control number. The valid OMB control number for this information
collection is xxxx-xxxx. The time required to complete this information collection is estimated to average XX minutes
per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have any comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C.
20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write
directly to: Institute of Education Sciences, National Center for Educational Evaluation, U.S. Department of
Education, 555 New Jersey Avenue, Room 500-i, Washington, D.C. 20208.

Part A. Your Background
These first questions ask some background information about you.
1.

Are you a…
a. Boy?
or
b. Girl?

2.

Are you Hispanic or Latino?
a.

No

b.

Yes

3.

What is your race? (Choose one or more.)
a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or other Pacific Islander
e. White

4.

When is your birthday?
Fill in the bubbles for the numbers that match your birthday, using 2 bubbles for month, 2 bubbles
for day, and 2 bubbles for year. For example, for June 11, 1994 fill in:
Month: 06

5.

a.

Month:

b.

Day:

c.

Year:

Day: 11

Year: 94

Which of these people do you live with most of the time? (Choose all that apply.)

a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

Mother
Stepmother
Foster mother, female guardian
Father
Stepfather
Foster father, male guardian
Sisters
Brothers
Children other than brothers or sisters
Grandparents
Other adults

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Part B. Your School
The following statements could describe a school. Think about your school over the
PAST 30 DAYS when answering the next few questions.
Strongly
agree
–

Agree
–

Disagree
–

Strongly
disagree
–

6.

Everyone knows what the school rules are ..............a ..............b .............. c ...............d

7.

The school rules are strictly enforced .......................a ..............b .............. c ...............d

8.

If a school rule is broken, students know
what kind of consequence will follow ........................a ..............b .............. c ...............d

9.

The punishment for breaking school rules is
the same no matter who you are ..............................a ..............b .............. c ...............d

10. Students are complimented or rewarded
when they follow the rules ........................................a ..............b .............. c ...............d
11. The rewards for following the rules are the
same no matter who you are ....................................a ..............b .............. c ...............d
12. We get taught at school about getting along
with others and about respecting them.....................a ..............b .............. c ...............d
13. We get taught at school about avoiding
and dealing with violent situations ............................a ..............b .............. c ...............d
14. Teachers or other adults at my school try
to prevent or stop bullying.........................................a ..............b .............. c ...............d
15. Teachers treat students with respect........................a ..............b .............. c ...............d

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Part C. Getting Along with People at Your School
The next questions are about things other students from your school may have done to
you in the PAST 30 DAYS.
In the PAST 30 DAYS, how many times did ANOTHER
STUDENT FROM YOUR SCHOOL:

Never
–

Almost
never
–

Sometimes
–

Often
–

16. Say or do something nice to you ..............................a ..............b ............... c ...............d
17. Say “thanks” or “you’re welcome” to you ..................a ..............b ............... c ...............d
18. Say or do something that made you feel good .........a ..............b ............... c ...............d
19. Invite you to participate in a game,
group conversation, or a class activity......................a ..............b ............... c ...............d
20. Say a compliment (praise, kind word) to you............a ..............b ............... c ...............d
21. Offer to help you .......................................................a ..............b ............... c ...............d
22. Share something with you ........................................a ..............b ............... c ...............d
23. Act friendly with you..................................................a ..............b ............... c ...............d
24. Show interest in your ideas or activities....................a ..............b ............... c ...............d

In the PAST 30 DAYS, how often did ANOTHER STUDENT
FROM YOUR SCHOOL:

Never
–

Almost
never
–

Sometimes
–

Often
–

25. Threaten to hit, push, slap, or shove you..................a ..............b ............... c ...............d
26. Actually hit, push, slap, or shove you .......................a ..............b ............... c ...............d
27. Threaten you (but not actually injure you)
with a weapon such as a gun, knife, or club .............a ..............b ............... c ...............d
28. Actually injure you with a weapon such as
a gun, knife, or club ..................................................a ..............b ............... c ...............d
29. Yell at you when they were angry ............................a ..............b ............... c ...............d
30. Throw something at you to hurt you .........................a ..............b ............... c ...............d
31. Pick a fight with you ..................................................a ..............b ............... c ...............d
32. Take, damage, or destroy on purpose
something that belonged to you................................a ..............b ............... c ...............d
33. Try to force you do something that you didn’t
want to do .................................................................a ..............b ............... c ...............d
34. Leave you out from a group or activity on purpose...a ..............b ............... c ...............d
35. Tell lies, spread rumors, or say mean things
about you to other students ......................................a ..............b ............... c ...............d
36. Call you an insulting name or word...........................a ..............b ............... c ...............d
37. Make fun of you in front of other people just
to be mean................................................................a ..............b ............... c ...............d

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The next questions ask about your behaviors in the PAST 30 DAYS.
In the PAST 30 DAYS, how many times did YOU:

Never
–

Almost
never
–

Sometimes
–

Often
–

38. Say or do something nice to a kid from
your school ...............................................................a ..............b ............... c ...............d
39. Say “thanks” or “you’re welcome” to a kid
from your school .......................................................a ..............b ............... c ...............d
40. Say or do something that made a kid from
your school feel good................................................a ..............b ............... c ...............d
41. Invite a kid from your school to participate
in a game, group conversation, or activity ................a ..............b ............... c ...............d
42. Compliment (praise, say a kind word)
a kid from your school...............................................a ..............b ............... c ...............d
43. Offer to help a kid from your school..........................a ..............b ............... c ...............d
44. Share something with a kid from your school ...........a ..............b ............... c ...............d
45. Act friendly with a kid from your school ....................a ..............b ............... c ...............d
46. Show interest in the ideas or activities of a kid
from your school .......................................................a ..............b ............... c ...............d

In the PAST 30 DAYS, how many times did YOU:

Did not
have the
opportunity
–

Never
–

Almost
never
–

Sometimes
–

Often
–

47. Stop someone from getting in a fight. ............ a ............... b ............. c ...............d ............. e
48. Protect someone from a “bully”...................... a ............... b ............. c ...............d ............. e

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In the PAST 30 DAYS, how often did YOU do each of
these things at school:

Never
–

Almost
never
–

Sometimes
–

Often
–

49. Threaten to hit, push, slap, or shove
another student.........................................................a ............ b............... c............... d
50. Actually hit, slap, shove, or push another student ....a ............ b............... c............... d
51. Bring a weapon such as a gun, knife, or club
to school ..................................................................a ............ b............... c............... d
52. Threaten (but not actually injure) another student
with a weapon such as a knife, gun, or club .............a ............ b............... c............... d
53. Actually injure another student with a weapon
such as a knife, gun, or club .....................................a ............ b............... c............... d
54. Get angry and yell at another student.......................a ............ b............... c............... d
55. Throw something at another student to hurt them ....a ............ b............... c............... d
56. Pick a fight with another student...............................a ............ b............... c............... d
57. Take, damage, or destroy on purpose
something that belonged to another student ............a ............ b............... c............... d
58. Try to force another student to do something
they didn’t want to do................................................a ............ b............... c............... d
59. Leave out another student on purpose from your
group or activity ........................................................a ............ b............... c............... d
60. Tell lies, spread rumors, or say mean things
about someone .........................................................a ............ b............... c............... d
61. Call another student an insulting name or word .......a ............ b............... c............... d
62. Make fun of another student in front of him
or her just to be mean...............................................a ............ b............... c............... d
The next questions ask about how safe you feel at school.
Never
–

Almost
never
–

Sometimes
–

Often
–

63. How often are you afraid that another student
from your school will attack or harm you? ................a ............ b............... c............... d
64. How often are you afraid that someone
from your school will bully you? ................................a ............ b............... c............... d

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Part D. Your Feelings and Attitudes
The next few questions ask about YOUR feelings and how you get along in general.
Please choose the answer that best describes how much you agree or disagree with
each of the following statements.
Strongly
agree
–

Agree
–

Disagree
–

Strongly
disagree
–

65. If I walked away from a fight, I’d be a coward
(“chicken”)..................................................................a .............. b ................c............... d
66. Anyone who won’t fight is going to be “picked on”
even more..................................................................a .............. b ................c............... d
67. I don’t need to fight because there are other ways
to deal with being mad...............................................a .............. b ................c............... d
68. It’s OK to hit someone who hits you first....................a .............. b ................c............... d
69. If a kid teases me or “disses” me, I usually cannot
get them to stop unless I hit them..............................a .............. b ................c............... d
70. Sometimes you have to physically fight
to get what you want..................................................a .............. b ................c............... d
71. Some kids deserve to be picked on or bullied ...........a .............. b ................c............... d
72. It’s OK to spread gossip about someone
to get even with them.................................................a .............. b ................c............... d
The next time you find yourself really angry at someone or about something, how likely
is it that YOU would...
Very
likely
–

Likely
–

Unlikely
–

Very
unlikely
–

73. Walk away or ignore the situation or person..............a .............. b ................c............... d
74. Try to talk it out with the other person........................a .............. b ................c............... d
75. Do something else to get your mind off of it ..............a .............. b ................c............... d
76. Laugh it off .................................................................a .............. b ................c............... d
77. Try to see the other person’s point of view ................a .............. b ................c............... d
78. Yell at the person.......................................................a .............. b ................c............... d
79. Break something........................................................a .............. b ................c............... d
80. Hit or threaten to hurt the person...............................a .............. b ................c............... d
81. Try calming yourself down .........................................a .............. b ................c............... d
82. Go talk with a friend ...................................................a .............. b ................c............... d
83. Apologize to the other person....................................a .............. b ................c............... d
84. Get help from a teacher or other adult.......................a .............. b ................c............... d

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