Student Survey
National Study to Inform the 21st Century Community Learning Centers (CCLC) Program (Second Study Component)
APPENDIX H_Student Survey
OMB: 1850-0966
Appendix
H:
Student Survey
OMB No.: xxxx-xxxx
Expiration Date: xx/xx/xxxx
U.S. DEPARTMENT OF EDUCATION
National Study of Continuous Quality Improvement to Inform the 21st Century Community Learning Centers Program
Student Survey
October 2021
SCRIPT FOR FIELD STAFF
Intro: Hi, my name is [name of field staff].
Your parent or guardian has given permission for you to participate in an important survey. We would like you to answer a few questions about the activities you do after school. To learn about how you think kids should behave, we will also describe a few made-up kids and ask you what you think about them.
The survey will take about 12 minutes and I will be here to answer any questions.
A few things...
You can choose whether or not to take this survey. We're excited to hear what you think and we hope you answer as many questions as you can, but it is OK to leave a question blank if you choose not to answer it.
Your answers will be kept private. Your answers will be combined with answers from other kids across the country. NO ONE will be told how you answered any of your questions. Your parents, teachers, and principal will not see your answers.
There are NO wrong answers. We want you to answer truthfully and as best you can. This is a chance for you to tell us what YOU think!
The first question asks you to think about things you did in the last month. When you are answering the question, think about what you did from [date one month prior to administering the survey] to today.
If you have any questions about your rights as a research volunteer, contact HML IRB toll free at 1-202-753-5040 and reference IRB number 844MATH21.
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label
A. Activities after school
The following question asks about your activities after school.
A1. Thinking about activities you did after school in the last month, how true is each of the following for you…
If it’s hard for you to make up your mind, take your best guess. There is no right or wrong answer.
SSIS Social and Emotional Learning Brief Scales (SSIS SELb; Elliott et al. 2020; 20 items)
This question will have 20 additional items. These items will consist of all 20 items in the SSIS SELb—Student 3-12 assessment. The items will ask students to self-report behaviors that reflect their social and emotional skills. For each item, they will select how true it is that they display each behavior (not true, a little true, mostly true, or very true). The SSIS SELb is proprietary.
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B. Understanding and controlling feelings
INSTRUCTIONS: You will now read about two made-up kids. We will ask you how well you think they can control their feelings.
Please choose a different answer for each kid.
B1. Sometimes Jada disagrees with another kid. When she does, she usually asks herself if she feels mad. Jada tells the other kid what she thinks but usually does not yell.
How true do you think it is that Jada understands and can control her feelings well?
MARK ONE ONLY
1 Not true
2 A little true
3 Mostly true
4 Very true
B2. Sometimes Darryl disagrees with another kid. When he does, he sometimes asks himself if he feels mad. Darryl tells the other kid what he thinks and sometimes yells.
How true do you think it is that Darryl understands and can control his feelings well?
MARK ONE ONLY
1 Not true
2 A little true
3 Mostly true
4 Very true
C. Understanding and getting along with other people
INSTRUCTIONS: You will now read about two made-up kids. We will ask you how well you think they get along with other people.
Please choose a different answer for each kid.
C1. Maya cannot often tell if another kid is sad. If she knows a kid is sad, she will sometimes say nice things to them. A few other kids find it hard to work with Maya on group projects.
How true do you think it is that Maya understands and gets along with other people?
MARK ONE ONLY
1 Not true
2 A little true
3 Mostly true
4 Very true
C2. Juan can usually tell when another kid is sad. If he knows a kid is sad, he will usually say nice things to them. One other kid finds it hard to work with Juan on group projects.
How true do you think it is that Juan understands and gets along with other people?
1 Not true
2 A little true
3 Mostly true
4 Very true
D. Doing the right thing
INSTRUCTIONS: You will now read about two made-up kids. We will ask you how well you think they do the right thing.
Please choose a different answer for each kid.
D1. If Chloe uses another kid’s toy, she is just as careful as she is with her own toys. Chloe tries to follow all rules but sometimes needs a reminder from an adult.
How true do you think it is that Chloe does the right thing?
MARK ONE ONLY
1 Not true
2 A little true
3 Mostly true
4 Very true
D2. If Noah uses another kid’s toy, he is less careful than he is with his own toys. Noah tries to follow most rules but often needs a reminder from an adult.
How true do you think it is that Noah does the right thing?
MARK ONE ONLY
1 Not true
2 A little true
3 Mostly true
4 Very true
E. Sticking with a goal
INSTRUCTIONS: You will now read about two made-up kids. We will ask you how good they are at sticking with a goal.
Please choose a different answer for each kid.
E1. To do better in school, Nina’s goal was to finish her homework before playing 5 days during the week. She finished her homework before playing 3 days during the week. Nina did not do better in school and decided she would not try any harder to finish her homework before playing the next week.
How true do you think it is that Nina is good at sticking with a goal?
MARK ONE ONLY
1 Not true
2 A little true
3 Mostly true
4 Very true
E2. To do better in school, Omar’s goal was to finish his homework before playing 5 days during the week. He finished his homework before playing 4 days during the week. Omar did not do better in school and decided he would try a little harder to finish his homework before playing the next week.
How true do you think it is that Omar is good at sticking with a goal?
MARK ONE ONLY
1 Not true
2 A little true
3 Mostly true
4 Very true
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Subject | TEMPLATE |
| Author | Dorothy Bellow |
| File Modified | 0000-00-00 |
| File Created | 2022-05-15 |
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