Student Report Survey

Student Survey

This survey is being given as part of a study to see how well the Lessons in Character Program is working. This survey asks about you, the student, and what you think about yourself, your school, your teachers, and your classmates. This school year and next school year you will be asked to complete similar surveys such as this one. Each one should take about 35 minutes to complete. No one at this school will know how you answered the survey . Your answers are private.

Please do NOT write your name on the survey. You do not have to answer all of the survey questions. Please write your answers on this survey paper. 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

Please contact Dr. Barbara Dietsch with any questions at 562.799.5126 or by email at bdietsc@wested.org.

According to the Paperwork Reduction Act of 1995, no persons are required to answer this survey unless it displays a valid OMB control number. The valid OMB control number for this information collection is 1850-0826. The time required to complete the survey should be about 35 minutes, including the time to review instructions. If you have any comments about the accuracy of the time estimate(s) or suggestions for improving this survey, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns about your individual submission of this form, write directly to: Rafael Valdivieso, U.S. Department of Education, 555 New Jersey Avenue, NW, Room 506E, Washington, D.C. 20208.

This collection of information is authorized by Public Law 107-279 Education Sciences Reform Act of 2002, Title I, Part C, Sec. 151(b) and Sec. 153(a). Participation is voluntary. Your responses are protected from disclosure by federal statute (PL 107-279 Title I, Part C. Sec. 183). All responses that relate to or describe identifiable characteristics of individuals may be used only for statistical purposes and may not be disclosed, or used, in identifiable form for any other purpose, unless otherwise compelled by law. Data will be combined to produce statistical reports. No individual data that links your name, address, telephone number, or identification number with your responses will be included in the statistical reports.

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

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.

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

42.	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
43.	I try hard to do well in school. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
44.	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
45.	I pay attention in class. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
46.	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
47.	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
48.	I don’t try very hard in school. 1 Disagree A LOT      2 Disagree a little      3 Agree a little      4 Agree A LOT
49.	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
50.	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
51.	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.

52.	I teased a kid at school. 1 Never      2 Once or twice      3 A few times      4 Many times
53.	I was sent home from school for bad behavior. 1 Never      2 Once or twice      3 A few times      4 Many times
54.	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
55.	I pushed, shoved, or hit a kid from school. 1 Never      2 Once or twice      3 A few times      4 Many times
56.	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
57.	I called a kid at school a bad name. 1 Never      2 Once or twice      3 A few times      4 Many times
58.	I said that I would hit a kid at school. 1 Never      2 Once or twice      3 A few times      4 Many times
59.	I left out another kid on purpose. 1 Never      2 Once or twice      3 A few times      4 Many times
60.	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
61.	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
62.	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
63.	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
64.	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

 

Thank you for taking this survey!