Students' Questionnaire

Background: This survey will provide information that will help to improve your school life and academic performance. Please do not place your name on this paper or any information that will identify you. This information will be confidential and none of the answers you give will be traced back to you. Thanks for taking part in this survey.

Instructions: Please select your school and grade and then select "No" or "Yes" next to each statement below.

Question Title

* 3. Health, Dental, and Hygiene Needs

  No Yes
When I am sick, my family is able to take me to the doctor.
I am able to visit the dentist at least once every school year.
I visit the eye doctor at least once every school year.
I have mouthwash, toothpaste and a toothbrush.
I have all that I need to keep my body clean.

Question Title

* 4. Emotional and Psychological Needs

  No Yes
I feel safe in my neighborhood.
I feel sad, lonely, angry, or scared a lot of the time.
I have seen someone get really hurt in my house and neighborhood.
Sometimes, when I feel sad or lonely, I do not come to school
Sometimes, when I feel sad or lonely, I  do not pay attention in school or do my schoolwork.
My friend talks about hurting himself or herself a lot.

Question Title

* 5. Home and Family Needs

  No Yes
I live with both of my parents.
Sometimes, my family is not able to pay the rent or house note.
Sometimes, my family is afraid of being kicked out of our home or apartment.
Our electricity, water, or gas was turned off during the school year.
Sometimes, I go home, and I am very hungry because there is no food.
There are always food and vegetables at my house or apartment.
One of my family members is in jail.

Question Title

* 6. Educational and Vocational Needs

  No Yes
I have all the school supplies I need for school.
My family is able to provide me with clothes for school.
I have a computer and internet at home.
I have books at home that I love to read.
When I need help with my homework, there is someone at home to help me.

Question Title

* 7. Social And Recreational Needs

  No Yes
My family takes me to the museums and other interesting places in the city.
I have a safe place to play and/or hang out with my friends after school.