FY 19-20 NM Youth Peer to Peer Helper Program YOUTH SELECTION SURVEY

Question Title

* 3. What grade are you in ?

5th grade

6th grade

7th grade

8th grade

9th grade

10th grade

11th grade

12th grade

Other (please specify)

Question Title

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

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Bi-racial or Multi-racial

Question Title

* 5. What is your gender?

Female

Male

Transgender

Self- Identify (please specify)

Question Title

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

Yes

Question Title

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

Yes

Question Title

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

Yes

Question Title

* 9. When I have a personal problem, I FIRST try to get help from:

Question Title

* 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

Abuse: emotional, physical, sexual and/or other threats of abuse

N/A

Achievements in school: grades and goals

N/A

Bullying: physical, mental, emotional and/or cyber

N/A

Career or college choices

N/A

Cutting or Harming Oneself

N/A

Depression/Sadness

N/A

Dropping out, being expelled, suspended etc.

N/A

Drug/alcohol

N/A

Eating disorders

N/A

Family: conflict, relationship, communication, etc.

N/A

Gangs/violence

N/A

Gossip/rumors

N/A

Loneliness

N/A

Loss: separation, divorce, death, etc.

N/A

Money issues: school/living expenses, getting a job, etc.

N/A

Peer pressure

N/A

Popularity/acceptance: fitting in, belonging, having friends etc.

N/A

Prejudice/racial discrimination

N/A

Romantic relationships/dating violence

N/A

Safe & acceptable activities & places to socialize with peers

N/A

Self-image: self-esteem, feeling good about yourself

N/A

Sex-related concerns: sexual identity, virginity, birth control etc.

N/A

Stress: not enough time, other pressures etc.

N/A

Teacher/administrator & student relationships

N/A

Thoughts of suicide

N/A

World issues: hunger, war, economy, natural disasters etc.

N/A

Question Title

* 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.

Question Title

* 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.

FY 19-20 NM Youth Peer to Peer Helper Program YOUTH SELECTION SURVEY

Question Title

* 1. Date

Question Title

* 2. Name of school/organization

Question Title

* 3. What grade are you in ?

Question Title

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

Question Title

* 5. What is your gender?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 9. When I have a personal problem, I FIRST try to get help from:

Question Title

* 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

Question Title

* 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.

Question Title

* 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.