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* 1. Which school do you attend?

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* 2. What is your gender?

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* 3. What grade are you in?

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* 4. Are you of Hispanic or Latino origin?

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* 5. What is your race?

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* 6. During the past 8 months, how would you described the grades you mostly received in school?

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* 7. During this school year, how many times were you absent from school?

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* 8. During this school year, how often have you been late to school?

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* 9. In the past 30 days, did you miss school for nay of the following reasons? ( Mark all that apply)

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* 10. I feel close to people at school.

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* 11. I am happy to be at this school.

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* 12. I feel like I am part of this school.

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* 13. The teachers at this school treat students fairly.

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* 14. I feel safe in this school.

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* 15. At my school, there is a teacher or some other adult who really cares about me.

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* 16. At my school, there is a teacher or some other adult who tells me when I do a good job.

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* 17. At my school, there is a teacher or some other adult who notices when I'm not there.

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* 18. At my school, there is a teacher or some other adult who always wants me to do my best.

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* 19. At my school, there is a teacher or some other adult who listens to me when I have something to say.

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* 20. At my school, there is a teacher or some other adult who believes that I will be a success.

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* 21. Since the beginning of this school year, how many times on school property have you been pushed, shoved, slapped, hit, or kicked by someone who wasn't just kidding around?

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* 22. Since the beginning of this school year, how many times on school property have you been afraid of being beaten up?

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* 23. Since the beginning of this school year, how many times on school property have you been in a physical fight?

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* 24. Since the beginning of this school year, how many times on school property have you had mean rumors or lies spread about you?

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* 25. Since the beginning of this school year, how many times on school property have you had sexual jokes, comments, or gestures made to you?

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* 26. Since the beginning of this school year, how many times on school property have you been made fun of because of your looks or the way you talk?

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* 27. Since the beginning of this school year, how many times on school property have you had your property stolen or deliberately damaged, such as your cell phone, clothing, or books?

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* 28. Since the beginning of this school year, how many times on school property have you been offered, sold, or given an illegal drug?

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* 29. Since the beginning of this school year, how many times on school property have you carried a gun?

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* 30. Since the beginning of this school year, how many times on school property have you carried any other weapon ( such as a knife or club)?

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* 31. Since the beginning of this school year, how many times on school property have you been threatened or injured with a weapon ( gun, knife, club, etc.)?

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* 32. Since the beginning of this school year, how many times on school property have you seen someone carrying a gun, knife, or other weapon?

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* 33. Since the beginning of this school year, how many times on school property have you been made fun of, insulted, or called names?

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* 34. Since the beginning of the school year, how many times on school property were you harassed or bullied for your race, ethnicity, or national origin?

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* 35. Since the beginning of the school year, how many times on school property were you harassed or bullied for your religion?

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* 36. Since the beginning of the school year, how many times on school property were you harassed or bullied for your gender (being male or female)?

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* 37. Since the beginning of the school year, how many times on school property were you harassed or bullied because you are gay or lesbian or someone thought you were?

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* 38. Since the beginning of the school year, how many times on school property were you harassed or bullied because of a physical or mental disability?

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* 39. Since the beginning of the school year, how many times on school property were you harassed or bullied because of any other reason?

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* 40. During the past 12 months, did you ever feel so sad or hopeless almost everyday for two weeks or more that you stopped doing some usual activities?

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* 41. If you could change one thing about your school what would that be?

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