Thank you for taking part in a 21st Century Community Learning Center program. We want to know what you think about school and this program. Please compete each part of the survey. Your answers will help us to develop programs that meet your needs.

* 1. Please select your gender.

* 2. Please select your race.

* 3. Please choose your current grade.

* 4. Which programs did you attend?

* 5. Please select 'Yes' or 'No' after reading each item.

  Yes No
I looked forward to attending this program.
This program helped me to know that success comes with effort NOT ability.
I am doing better in school because of this program.
Because of this program, I know I can do better in school if I work harder.
I feel safe in school.
I can talk with the teacher who leads my program about alot of different topics.
I like this program.
I know what to do when another student breaks the rules.
Students know what to do when being bullied in-person or on-line.
Have you ever seen a student carrying a weapon at school.
You have seen fights at school.
My teacher or teachers help me when I struggle in school.
My teacher or teachers calls me by name.

* 6. Please tell us jow much you like each of the subjects you learn in school. Use numbers from 1 (most favorite), 2, 3, 4, 5, to 6 (least favorite).

* 7. Please list the places in school where you do not feel safe?

* 8. How safe do you feel in school?

* 9. Please select how serious the following problems are in your school.

  Don't Know No Problem Small Problem Serious Problem
Alcohol Use
Tobacco Use
Drug Use
Drug Selling
Carrying Weapons
Conflict between Students

T