Instructions:

This survey is about the students of Burke County. It asks about your behavior, experiences, and attitudes related to health, well-being, and schooling. It includes questions about use of alcohol, tobacco, and other drugs; bullying and violence; and what you do at school and how you feel about it.

You do not have to answer these questions, but your answers will be very helpful in improving your school's climate.

Simply check the box or boxes that best express your answer.

Please notice this survey asks about things you may have done during different periods of time, such as the past 12 months, or the past 30 days, or the past week. Each provides different information. Please pay careful attention to these time periods.

* 2. How old are you?

* 3. What is your gender?

* 4. What grade are you in?

* 5. What school do you attend?

* 6. How do you describe yourself?

* 7. On an average school day, how many hours do you...

  None Less than 1 hour per day 2 hours per day 3 hours per day 4 hours per day 5 or more hours per day
Watch TV?
Play video or computer games?
Spend on Facebook or Myspace?
Spend on the Internet for something not school-related?
Play sports or play outside after school?

* 8. Which of the following activities do you do regularly?

* 9. How strongly do you agree or disagree with the following statements about your school?

  Strongly Disagree Disagree Neither Disagree Nor Agree Agree Strongly Agree
I feel close to people at this school.
I am happy to be at this school.
I feel like I am part of this school.
The teachers at this school treat students fairly.
I feel safe in my school.
I feel safe riding the school bus.
I help make class rules or school rules.

* 10. At my school, there is a teacher or some other adult...

  Not At All True A Little True Pretty Much True Very Much True
Who really cares about me.
Who tells me when I do a good job.
Who notices when I'm not there.
Who always wants me to do my best.
Who listens to me when I have something to say.
Who believes that I will be a success.

* 11. During the past year...

  Yes No
I have talked to a counselor AT my school about a personal problem.
I have talked to a counselor OUTSIDE my school.

* 12. During this school year, on how many DAYS did you...

  0 days 1 day 2 days 3-9 days 10-19 days 20-30 days
Use cigarettes or chewing tobacco?
Have at least one drink of beer or wine?
Take drugs your parents did not give you?

* 13. During this school year, how many times have you...

  0 times 1 time 2-3 times 4 or more times
Been pushed, shoved, slapped, hit, or kicked at school by someone who wasn't just kidding around?
Been afraid of being beaten up at school?
Been in a physical fight at school?
Been bullied or harassed at school?
Had mean rumors or lies spread about you at school?
Had your property, such as clothing or books, stolen or deliberately damaged at school?
Carried a knife or gun at school?
Seen someone carrying a gun, knife, or other weapon at school?

* 14. In the last month, how many days...

  0 days 1 day 2-3 days 4 or more days
Did you stay out of school because you felt unsafe at school or unsafe on your way to or from school (walking, riding the bus, etc.)?

* 15. How many of these questions did you understand?

Thank you!

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