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* 1. My current grade:

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* 2. Homeroom teacher's name:

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* 3. This school year, I’ve been suspended from school (in-school suspension or off-campus):

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* 4. This school year, I’ve been disciplined at school for being “disrespectful,” “disruptive” or verbally or physically violent or other reasons:

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* 5. The No. 1 adult at school that I feel safe sharing my struggles with, or asking for help, is:

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* 6. When a person(s) upsets me at school, I usually:

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* 7. Please rate the following statements:

  Strongly Agree Agree Not Sure Disagree Strongly Disagree
I look forward to going to school.
I feel the adults at my school respect me and are interested in me.
I feel the adults at my school care about me.
The adults at my school listen to me.
I feel I have important contributions to make to my school or community.
It’s hard for me to listen to others without wanting to interrupt or comment.
I have goals in my life based on what I’m passionate about.
I set boundaries with others to make sure I reach my goals.
It’s hard for me to ask for help sometimes.
I worry about making mistakes and sometimes it prevents me from trying new things.
I listen to myself above others.

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* 8. The definition of respect this year (check all that apply):

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* 9. The Respect Basic that helps me the most is:

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* 10. My homeroom completed our journal:

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* 11. My favorite activities were (check all that apply):

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* 12. What is the No. 1 thing that would help you feel more welcome at CMS?

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* 13. Did "respect" improve on campus over the course of the school year?

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