Safe Schools/Healthy Students - 2014 Burke County Middle School Student Questionnaire

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 answers.

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.
1. What is your teacher's name?
2. Please tell us a little about yourself. 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. The next questions ask about food you ate or drank during the PAST WEEK. Think about all the meals and snacks you had from the time you got up until you went to bed. Be sure to include food you ate at home, at school, at restaurants, or anywhere else. During the PAST WEEK, how many times did you eat/drink...
Did not eat/drink this1-2 times3-4 times5-6 times7-8 times9-10 times11 or more times
Fruit? (Do not count fruit juice.)
Green salad?
Carrots?
Other vegetables?
A can, bottle, or glass of soda, such as Coke, Pepsi, Sprite or sports drink? (Do NOT include diet soda.)
8. On an average school day, how MANY HOURS do you...
NoneLess than 1 hour per day2 hours per day3 hours per day4 hours per day5 or more hours per day
Watch TV?
Play video or computer games?
Spend on Facebook or MySpace
Spend on the Internet in an online group or community that is NOT Facebook or MySpace?
Spend texting with others?
9. During the PAST 7 DAYS, on how many days were you physically active for a total of at least 60 minutes per day? (Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.)
10. During the LAST SCHOOL WEEK, how many hours of sleep did you get most nights?
11. Please mark how TRUE you feel each of the following statements is about your SCHOOL. How strongly do you agree or disagree with the following statements about your school?
Strongly DisagreeDisagreeNeither Disagree Nor AgreeAgreeStrongly 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 do interesting activities at school.
Teachers promote academic success for all students.
Students at this school belong to a gang.
12. At my school, there is a teacher or some other adult...
Not At All TrueA Little TruePretty Much TrueVery 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.
Who believes I will continue my education beyond high school.
Whom I trust.
13. During the PAST YEAR...
YesNo
I have talked to a counselor at my school about a personal problem.
I have talked to a counselor OUTSIDE my school.
I have talked to an adult in the school besides a counselor about a personal problem.
I have talked to the School Resource Officer (SRO) about a problem.
My parents have talked with a teacher at my school.
My parents have attended a school function.
14. Which of the following activities, do you do regularly? Check ALL that apply.
15. The next questions ask about the use of alcohol, tobacco, marijuana, and other drugs. DURING the PAST 30 DAYS, on how many DAYS did you use...
0 days1 day2 days3-9 days10-19 days20-30 days
Cigarettes?
Smokeless tobacco (dip, chew, or snuff)?
At least one drink of alcohol?
Five or more drinks of alcohol within a couple of hours?
Marijuana (pot, weed, grass, hash, bud)?
Any other illegal drug or pill to get "high"
16. The next questions ask about the use of drugs without a doctor's order (prescription for medical reasons). During the PAST 30 DAYS, on how many DAYS did you use...
0 days1 day2 days3-9 days10-19 days20-30 days
Prescription pain killers (Vicodin, Oxycontin, etc.)
Barbituates (Seconal, Nembutol, Amital, reds, yellow jackets)
Tranquilizers or sedatives, (tranks, Xanax, Valium, Ativan, Librium)
Diet Pills (Didrex, Dexedrine, Zinadrine)
Ritalin or Adderall (JIF, R-ball, Skippy, the smart drug)
17. The next questions ask about the effects of using alcohol, tobacco, and marijuana. How much do people risk harming themselves physically and in other ways when they do the following?
No risk of harmSlight risk of harmModerate risk of harmGreat risk of harm
Smoke one to two packs of cigarettes each day
Have five or more drinks of an alcoholic beverage once or twice a week
Smoke marijuana occasionally
Smoke marijuana once or twice a week.
18. During the LAST 30 DAYS, how many DAYS did you did you not go to school because you felt unsafe...
0 days1 day2-3 days4-5 days6 or more days
At school or on the way to and from school?
On the bus?
Walking to school?
19. In the PAST 12 MONTHS, how many times have you...
0 times1 time2-3 times4 or more times
Been bullied or harassed through the computer (email, instant messaging, web posting)?
Been bullied or harassed by cell phone (text messaging)?
Received an inappropriate picture (sexting)?
20. During the PAST 12 MONTHS, how many times on SCHOOL PROPERTY have you...
0 times1 time2-3 times4 or more times
Been pushed, shoved, slapped, hit, or kicked by someone who wasn't just kidding around?
Been afraid of being beaten up?
Been in a physical fight?
Been bullied or harassed?
Had mean rumors or lies spread about you?
Had sexual jokes, comments, or gestures made to you?
Had your property stolen or deliberately damaged, such as your car, clothing, or books?
Carried a gun?
Carried any other weapon (such as a knife or club)?
Seen someone carrying a gun, knife, or other weapon?
21. The next four questions ask about sad feelings and attempted suicide. Sometimes people feel so depressed about the future that they may consider attempting suicide, that is, taking some action to end their own life. During the PAST 12 MONTHS, did you...
YesNo
Ever feel depressed (so sad or hopeless that you stopped doing some of your usual activities almost every day for at least two weeks)?
Ever seriously consider attempting suicide?
Make a plan about how you would attempt suicide?
Attempt suicide?
22. During the PAST 12 MONTHS, how would you describe the grades you mostly received in school?
23. How many questions in this survey did you answer honestly?
Thank you!
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