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* 1. Date

Date / Time

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* 3. What grade are you in ?

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* 4. Which race/ethnicity best describes you? (Choose all that apply)

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* 5. What is your gender? 

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* 6. When I have a personal problem, I have a trusted friend near my own age that I can talk to and get help

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* 7. When I have a personal problem, I have a trusted adult in my school that I can talk to and get help

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* 8. When I have a personal problem, I have a trusted adult outside of school that I can talk to and get help

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* 10. What are the top five (5) greatest concerns for you and your friends at your school or organization? Please indicate which is most concerning with 1 being the most concerned and 5 being the least

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* 11. Please write the first and last name of TWO (2) YOUTH at your school/organization that you believe are honest, trustworthy and caring. They should be youth you would feel comfortable going to with a personal problem and who would show concern for fellow students and their community.

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* 12. Please write the first and last name of TWO (2) ADULTS at your school/organization that you believe are honest, trustworthy and caring. They should be youth you would feel comfortable going to with a personal problem and who would show concern for fellow students and their community.

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