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* 1. What is the name of your school?

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* 2. What grade are you in?

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* 3. Do you feel close to people at school?

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* 4. Are you happy to be at this school?

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* 5. Do you feel like you are part of this school?

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* 6. Do the teachers and other grown-ups at school care about you?

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* 7. Do the teachers and other grown-ups at school tell you when you do a good job?

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* 8. During the past year, how many times have you hit or pushed other kids at school when you were not playing around?

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* 9. Do other kids hit or push you at school when they are not just playing around?

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* 10. Do the teachers and other grown-ups at school listen when you have something to say?

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* 11. Do the teachers and other grown-ups at school believe that you can do a good job?

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* 12. Do other kids at school spread mean rumors or lies about you?

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* 13. Do other kids at school spread mean rumors or lies about you on the internet (i.e. Facebook, emails, instant messaging?

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* 14. During the past year, how many times have you been absent from school?

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* 15. During the past year, how many times have you been late to school?

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* 16. Are you home alone after school?

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* 17. Do you feel safe at school?

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* 18. Do you feel safe outside of school?

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* 19. Do you know where to go for help with a problem?

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* 20. Does a parent or some other grown-up at home care about your schoolwork?

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* 21. Does a parent or other grown-up able to help you with homework when you have a question?

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* 22. Does a parent or some other grown-up at home believe that you can do a good job?

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

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