Form Student Survey Dat Student Survey Dat Student Survey Data Abstraction

ATTACHMENT 8:

STUDENT SURVEY DATA ABSTRACTION PROTOCOL

OMB No. 0930-XXXX

Exp. Date MM/DD/YYYY

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-0xxx.  Public reporting burden for this collection of information is estimated to average 1 hour and 30 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57-B, Rockville, Maryland, 20857.

Example Student Survey Data Abstraction Protocol

Instructions: Please provide information for EACH student survey. Enter 0 (zero) for no students. Enter DK if the information is unknown or not available. Enter NA if not applicable.

Name of student survey: ___________________________________________

School year data were collected: ______________________

School Information

LEA Name: __________________________________

School Name: __________________________________

Number of students who completed the student survey, by grade level:

____6 ____7 ____8 ____9 ____10 ____11 ____12 ____Other (specify: ____)

1. School Climate

   1. Staff-Student Relationships

      1. Personalized learning, feedback

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
My teachers give me individual attention when I need it.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
My teachers tell me when I do a good job.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Students are often given rewards for being good.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
My teachers praise me when I work hard in school.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

2. Respectful, supportive, caring

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
My teachers treat me with respect.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I know an adult at school that I can talk with if I need help.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Teachers care about their students.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
My teachers notice when I am absent.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

2. Student-Student Relationships

   1. Respectful, supportive, caring

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
Students in my school treat each other with respect	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Students in this school help each other, even if they are not friends	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
In this school, students care about each other.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Students at this school get along well with each other.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

3. Student Connectedness To School

   1. School pride, liking

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
Students speak about the school in proud, positive terms.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Now thinking back over the past year in school, how often did you: Enjoy being at school?	Never
	Seldom
	Sometimes
	Often
	Almost Always
I look forward to going to school most days.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I care about my school.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

4. Problems Posed By Student Risk Behavior

   1. Consequences of problem behaviors

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
Disruptions by other students get in the way of my learning	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Students are sometimes distracted in class because they are drunk or high.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
In the past year, which of the following happened because you drank alcohol or used drugs? Choose all that apply	I did not use alcohol or drugs in the past year.
	I did not have any problems from drinking alcohol or using drugs in the past year.
	I missed classes or school.
	I failed classes or dropped out of school.
	I got sick (vomited) or had a hangover.
	I felt depressed, anxious, scared, or had other emotional problems.
	I got hurt or injured.
	I hurt or injured someone else.
	I got in trouble with my parents or family.
	I did things I didn’t want to do or regretted afterward.

5. Student Academic Achievement

   1. Grades in School

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 12 months, how would you describe your grades in school?	Mostly A’s
	Mostly B’s
	Mostly C’s
	Mostly D’s
	Mostly F’s
	None of these grades
	Not sure
I get good grades in school.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

6. Clarity of Expectations

   1. Clear behavioral/academic expectations

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
Everyone knows what the school rules are.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Teachers make it clear to me when I have misbehaved in class.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I know what it takes to get a good grade in my classes.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

7. Respect for Diversity

   1. Student-to-student

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
I get along well with students who are different from me.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Students at my school are often friends with students from different races, religions, and cultures.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Students at my school respect each other’s differences.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
Students at this school are teased or picked on about their cultural background or religion.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

2. Teacher-to-student

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
Adults in this school respect differences in students (for example, gender, race, culture, learning differences, sexual orientation, etc.)	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
In this school, adults care about students of all races.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
In the past 30 days, how often have you seen an adult at school say something mean or hurtful to a student based upon the students cultural background, ethnicity, or identity?	Never
	One time
	Sometimes (2 to 3 times a month)
	Fairly Often (every week)
	Very Often (every day or nearly every day)

8. Fairness of Rules

   1. Fairness of rules

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
The school rules are fair.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
In the past 30 days, how often were the statements below true for you while at school? I felt that consequences at school for mean or hurtful behavior were fair.	Never or almost never
	Some of the time
	Most of the time
	Always or almost always
School rules are applied equally to all students.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
In this school, the consequences of breaking rules are fair.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

2. Enforcement

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
The school principal and teachers consistently enforce school rules.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
In this school, teachers use just enough punishment; not too much or too little.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
If I skipped school at least one of my parents/guardians would be notified.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I feel like adults at this school follow the rules and procedures.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

9. Student Engagement

   1. School/Coursework engaging/important

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
How often do you feel that the school work you are assigned is meaningful and important?	Never
	Seldom
	Sometimes
	Often
	Almost Always
How interesting are most of your courses to you?	Very interesting and stimulating
	Quite interesting
	Fairly interesting
	Slightly dull
	Very dull
My teachers often connect what I am learning to life outside the classroom.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
At this school, I do things that make a difference.	Not at all true
	A little true
	Pretty much true
	Very much true

2. Engaged in class/school activities

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
I pay attention in class.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I do the homework that is assigned.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I have lots of chances to be part of class discussions or activities.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

10. Student Autonomy

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
In my school, students are given a change to help make decisions.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I feel like the students and teachers here try to decide together what the class rules will be.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I feel my basic need for power, belonging, freedom and fun are mostly met.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I feel motivated and in control of my learning.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

2. School Safety

   1. Perceptions of School Safety

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
I sometimes stay home because I don’t feel safe at this school.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
During the past 30 days, on how many days did you not go to school because you felt you would be unsafe at school or on your way to or from school?	0 days
	1 day
	2 or 3 days
	4 or 5 days
	6 or more days
I feel safe at my school.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

2. Victimization

   1. Bullying

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 12 months, have you ever been bullied on school property?	Yes
	No
During the past 12 months, have you ever been electronically bullied? (Include being bullied through e-mail, chat rooms, instant messaging, websites, or texting.)	Yes
	No
Students at this school are often teased or picked on	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

2. Dating Violence

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 12 months, how many times did someone you were dating or going out with physically hurt you on purpose? (Count such things as being hit, slammed into something, or injured with an object or weapon.)	I did not date or go out with anyone during the past 12 months
	0 times
	1 time
	2 or 3 times
	4 or 5 times
	6 or more times
Have you ever been physically forced to have sexual intercourse when you did not want to?	Yes
	No
During the past 12 months, how many times did someone you were dating or going out with physically hurt you on purpose? (Count such things as being hit, slammed into something, or injured with an object or weapon.)	I did not date or go out with anyone during the past 12 months
	0 times
	1 time
	2 or 3 times
	4 or 5 times
	6 or more times

3. Physical Fights

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 12 months, how many times were you in a physical fight?	0 times
	1 time
	2 or 3 times
	4 or 5 times
	6 or 7 times
	8 or 9 times
	10 or 11 times
	12 or more times
During the past 12 months, how many times were you in a physical fight in which you were injured and had to be treated by a doctor or nurse?	0 times
	1 time
	2 or 3 times
	4 or 5 times
	6 or more times
During the past 12 months, how many times were you in a physical fight on school property?	0 times
	1 time
	2 or 3 times
	4 or 5 times
	6 or 7 times
	8 or 9 times
	10 or 11 times
	12 or more times

4. Weapons Carrying

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 30 days, on how many days did you carry a gun?	0 days
	1 day
	2 or 3 days
	4 or 5 days
	6 or more days
During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club on school property?	0 days
	1 day
	2 or 3 days
	4 or 5 days
	6 or more days
During the past 30 days, on how many days did you carry a weapon such as a gun, knife, or club?	0 days
	1 day
	2 or 3 days
	4 or 5 days
	6 or more days

5. Other Delinquent Behaviors

   1. Tobacco use

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 30 days, on how many days did you smoke cigarettes?	0 days
	1 or 2 days
	3 to 5 days
	6 to 9 days
	10 to 19 days
	20 to 29 days
	All 30 days
During the past 30 days, on how many days did you smoke cigars, cigarillos, or little cigars?	0 days
	1 or 2 days
	3 to 5 days
	6 to 9 days
	10 to 19 days
	20 to 29 days
	All 30 days
During the past 30 days, on how many days did you use chewing tobacco, snuff, or dip, such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?	0 days
	1 or 2 days
	3 to 5 days
	6 to 9 days
	10 to 19 days
	20 to 29 days
	All 30 days
During the past 30 days, on how many days did you use an electronic vapor product?	0 days
	1 or 2 days
	3 to 5 days
	6 to 9 days
	10 to 19 days
	20 to 29 days
	All 30 days

2. Alcohol use

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 30 days, on how many days did you have at least one drink of alcohol?	0 days
	1 or 2 days
	3 to 5 days
	6 to 9 days
	10 to 19 days
	20 to 29 days
	All 30 days
During the past 30 days, on how many days did you have 5 or more drinks of alcohol in a row, that is, within a couple of hours?	0 days
	1 day
	2 days
	3 to 5 days
	6 to 9 days
	10 to 19 days
	20 or more days
During the past 30 days, how many times did you drive a car or other vehicle when you had been drinking alcohol?	I did not drive a car or other vehicle during the past 30 days
	0 times
	1 time
	2 or 3 times
	4 or 5 times
	6 or more times

3. Other illegal drug use

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 30 days, how many times did you use marijuana?	0 times
	1 or 2 times
	3 to 9 times
	10 to 19 times
	20 to 39 times
	40 or more times
During your life, how many times have you used any form of cocaine, including powder, crack, or freebase?	0 times
	1 or 2 times
	3 to 9 times
	10 to 19 times
	20 to 39 times
	40 or more times
During your life, how many times have you taken a prescription drug (such as OxyContin, Percocet, Vicodin, codeine, Adderall, Ritalin, or Xanax) without a doctor’s prescription?	0 times
	1 or 2 times
	3 to 9 times
	10 to 19 times
	20 to 39 times
	40 or more times
During your life, how many times have you used heroin (also called smack, junk, or China White)?	0 times
	1 or 2 times
	3 to 9 times
	10 to 19 times
	20 to 39 times
	40 or more times

3. Mental Health

   1. Sadness/Hopelessness

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing some usual activities?	Yes
	No
How often did you feel any of the following mental or physical discomforts in the past week?: I was sad or had little interest in doing things.	Never
	Seldom
	Sometimes
	Often
How often did you feel any of the following mental or physical discomforts in the past week?: The future seemed hopeless.	Never
	Seldom
	Sometimes
	Often

2. Signs of Suicide

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
During the past 12 months, did you ever seriously consider attempting suicide?	Yes
	No
During the past 12 months, did you make a plan about how you would attempt suicide?	Yes
	No
During the past 12 months, how many times did you actually attempt suicide?	0 times
	1 time
	2 or 3 times
	4 or 5 times
	6 or more times
If you attempted suicide during the past 12 months, did any attempt result in an injury, poisoning, or overdose that had to be treated by a doctor or nurse?	I did not attempt suicide during the past 12 months
	Yes
	No

3. Anxiety

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
How often over the last 2 weeks were you bothered by: Feeling nervous, anxious or on edge?	Not at all
	Several days
	More than half the days
	Nearly every day
I am worried that something bad is going to happen	Almost Always
	Often
	Sometimes
	Never
During the past 30 days (month), how often did you: Feel stressed?	Almost Always
	Often
	Sometimes
	Never

4. Coping/Resiliency

   1. Self-Regulation/Self-Control

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
I think things through carefully before I make a decision.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
I am good at waiting for what I want.	Not like me at all
	Not much like me
	Somewhat like me
	Very much like me
I control myself when I am frustrated, angry, or disappointed.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree

2. Self-Confidence

Survey Items	Response Options	Frequency
		Grade								Total
		6	7	8	9	10	11	12	O
I believe I can do well at this school.	Strongly Agree
	Agree
	Disagree
	Strongly Disagree
With 0 being “not at all true,” and 10 being “completely true,” please fill in the number on the scale that best describes how closely this statement applies to you: I feel good about myself.	0 Not at all true
	1
	2
	3
	4
	5
	6
	7
	8
	9
	10 Completely true
I have a definite sense of purpose in life.	Strong Disagree
	Disagree
	Agree
	Strongly Agree