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1. Today's Date (Required.)

Date

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2. Your Age (Required.)

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3. Birth Gender (Required.)

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4. Class Period (Required.)

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5. In the past month, how often have you felt overwhelmed by your emotions? (Required.)

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6. When you feel sad or upset, do you have someone you can talk to about it? (Required.)

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7. How often do you feel hopeful about your future? (Required.)

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8. Do you think it’s okay to ask for help if you’re feeling anxious or depressed? (Required.)

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9. How connected do you feel to your peers at school? (Required.)

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10. In the past 12 months, have you felt excluded or left out by your peers? (Required.)

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11. How often do you participate in social activities with friends outside of school? (Required.)

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12. On an average school night, how many hours of sleep do you get? (Required.)

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13. How often do you engage in physical activity or exercise? (Required.)

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14. In the past 30 days, how often have you felt physically tired during the school day? (Required.)

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15. Do you feel that you have a sense of purpose or direction in your life? (Required.)

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16. How often do you reflect on things that matter most to you? (Required.)

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17. When faced with a problem, how confident are you in your ability to handle it? (Required.)

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18. In the past 30 days, how often have you felt able to manage stress effectively? (Required.)

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19. In the past 12 months, have you experienced bullying (in person or online)? (Required.)

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20. Do you feel safe at school? (Required.)

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21. Do you know where to go for help at school if you’re feeling unsafe or need support? (Required.)

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