Dear Student: Please take a moment to answer the following questions.  

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* 1. Which school do you attend?

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* 2. What is your grade level?

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* 3. Please respond to the following questions and be honest - there are no right or wrong answers.

  Yes Usually Not really No
Are you a good student?
Are you confident in yourself and your abilities?
Are you comfortable being a leader?
Are you comfortable asking a teacher for help when you do not understand your school work?
Are you comfortable voicing your opinion?
Do you show respect for others' ideas?
Do you get along with others who are different from you?
Do you treat others the way you want to be treated?
Do you think about how your choices affect others?
Before making a decision, do you stop and think about your choices?
Do you try to learn from your mistakes?
Are you willing to work hard on something difficult?
Do you set goals for yourself?
Do you bounce back from setbacks and disappointments easily?
Do you like to learn new things?
Is your homework completed on time?
Do you actively participate in class discussions?
Is getting good grades important to you?
Do you think it is important to go to college?
Do you like going to school?
Do you understand what you are learning in your classes?
Do you understand the connection between what you are learning in school and how it will be useful in college and/or future career?
Do you believe you need to do well in school to reach your future goals?
Do you feel a sense of belonging at your school?
Do you feel cared for at home?
Do you feel safe at school?
Do you feel like you can share your feelings at home?
Do you feel like you can share your feelings at school?
Do you feel you express your behavior appropriately at school?
Do you feel you express your behavior appropriately outside of school?

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* 4. Please indicate your level of interest in participating in activities related to each of the following areas.

  Very interested Interested Not very interested Not at all interested
Homework Help/Improving Grades
Career Exploration
Community Service Projects
Science
Technology
Engineering
Mathematics
Reading/Literacy
Arts
Music/Chorus
Theater/Drama
Health and Nutrition
Sports, Fitness, and Recreation
Life Skills/Personal Development
Financial Literacy

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* 5. What type of career field(s) are you interested in pursuing or learning more about?  Check all that apply.

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