We would like to have feedback from YOU. This information will help us understand a bit more about you and help us to improve the program.

* 1. Test Type

* 2. What school do you attend?

* 3. What is your name?

* 4. What is your Student Identification Number?

* 5. What is today's date?

Date
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* 6. Instructions: Please select the answer that best represents how you think and feel.

  Agree a LOT Agree a Little Not Sure Disagree a Little Disagree a LOT
It is easy for me to talk about my feelings.
If I have an argument, I try to work it out with the other student.
I yell at other students when I am mad.
I know many different words to describe what I feel inside.
If a student bothered me, I would walk away.
I can calm myself down when I am upset.
I push or shove students who make me mad.
If I have a conflict, I ask to hear the other student’s side of the story.
I ask other students what they feel if I am not sure.
I call other students names when I am mad.
I try to think of many different ways to solve a problem.
I stop and think before I act when I am mad or upset.
I will ask a student to play if they don't have someone to play with.
I listen to other students even when I disagree.
I tell other students how I feel when they do something I like.
I tell other students how I feel when they do something I don’t like.

* 7. What is your age today?

* 8. What grade are you in?

* 9. Are you a boy or girl?

* 10. How do you describe yourself?

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