This survey is to help your school learn more about your needs as a student. This survey should take no more than 10 minutes. You will not be asked to identify yourself. If you need help with reading or understanding the questions, please ask for assistance from the staff. If at any time you feel uncomfortable completing this survey or if you have questions, please let the school staff know.

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* 1. Select the name of your Learning Site/School.

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* 2. What is your current grade level in high school?

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* 3. Do you currently work for pay?

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* 4. If you do work for pay, how many hours do you work per week?

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* 5. How many schools have you attended in the last five years?

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* 6. In the past two months have you been the target of bullying at this school?

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* 7. In the past two months have you witnessed bullying at this school?

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* 8. Please answer each of the following statements indicating your level of agreement.

  Strongly disagree Disagree Agree Strongly agree
It is important that I log into my school work each school day.
It is important to me that I graduate
I’d rather work than go to school
I am treated with respect by the school staff
I feel successful at this school
 I plan on going to a technical school or a college/university when I graduate.
The students here are expected to follow school rules.
The school staff have confidence in me and expect me to do my best
I feel that I am treated unfairly because of my language, race, religion or gender identify
I need to take care of my child or other family member during the school.
The school staff let me know when I am doing well and on track to complete my courses by the end of the semester.
The adults at this school believe I can go to college or technical school after I graduate.
I have a teacher or an adult  I can go to when I don’t feel safe or someone is giving me problems.
I need to help my family by earning money.
I have a hard time keeping up with my school work.
I am on track to graduate on time.
Students in the class treat the school staff with respect
The staff at the school help me when I don’t understand my work
I have health concerns, including pregnancy or mental health issues, that keep me from completing my coursework.
I know how many credits I need to earn before I graduate.
It is important to my family that I graduate.
It is important to me to get good grades.
I think the school is safe for students
It is important to the school staff that I graduate
One or more of my family members have dropped out of school before graduating.
I have been bullied at this school because of my race, religion, language or gender identify.
I feel the school staff know and care about me
There is a regular schedule of classes that we follow.
Sometimes problems at home impact my ability to complete my coursework.

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* 9. List 2-3 goals that you have for high school and after high school.

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* 10. What can the school do to help you achieve your goals?

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