Example - Staff Survey

Attachment 4: Sample Quantitative Instrument

DASH 1308-Strategy 4 Project: School Staff Survey

	Form Approved OMB No. 0920-xxxx Exp. Date xx/xx/xxxx Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New) To help you answer the questions accurately, some definitions of words you may encounter in the survey are listed below. Definitions: Sexual orientation refers to an individual's physical and/or emotional attraction to the same and/or opposite gender. Gender expression refers to how traditionally “masculine” or “feminine” one is in his/her appearance or in how he/she acts. Gender identity refers to a person's innate, deeply felt psychological identification as male or female, which may or may not correspond to the person's body or designated sex at birth.
	ABOUT YOU
	Please tell us about yourself.
	School name: Drop down menu
	Role: Administrator Teacher Nurse Counselor/Psychologist Social worker Other, please specify: _________________________________
	How long have you been working in your current role? 1 year or less 2-5 years 6-10 years 11 or more years
	STUDENT EXPERIENCES AT SCHOOL
	For the following set of questions, please select the answer that best describes your impression of student experiences at your school.
	In general, do you think that students feel safe at your school? Yes No I Don’t Know
	Do you think students feel unsafe at your school because of their perceived sexual orientation? Yes No I Don’t Know
	In your opinion, to what extent is each of the following a problem in your school? (Matrix) Response Options: Serious problem Moderate problem Minor problem Not a problem I Don’t Know Items: Student tardiness Student absenteeism Student class cutting
	In your opinion, to what extent is each of the following a problem in your school among lesbian, gay, bisexual, transgender, and questioning (LGBTQ) students? (Matrix) Response Options: Serious problem Moderate problem Minor problem Not a problem I Don’t Know Items: Student tardiness Student absenteeism Student class cutting
	QUESTIONS ABOUT BULLYING
	Bullying is when 1 or more students tease, threaten, spread rumors about, hit, shove, or hurt another student over and over again. It is not bullying when 2 students of about the same strength or power argue or fight or tease each other in a friendly way. Bullying is unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time. This includes verbal, physical, social, and cyberbullying and may occur on or off school grounds.

	Have you talked to students about bullying during the current school year? Yes No
	Prejudice is defined as negative or inaccurate beliefs about another group of people without basis in experience or facts. In your opinion, to what extent is prejudice against LGBTQ students a problem in your school? (Matrix) Response options: Serious problem Moderate problem Minor problem Not a problem Items: From school staff From other students
	During the current school year, how many students have you seen or heard being bullied? Response options: Number (Drop down menu of numbers ranging from 0-25, with the final option of ‘26 or more’) (if 0, Skip to 14)
	Why do you think students were bullied during the current school year? Please select all that apply. Their gender Their gender expression Their sexual orientation or perceived sexual orientation Their race or ethnicity or perceived race or ethnicity Their family’s income or economic status or perceived income or economic status Their religion or perceived religion Their citizenship status or perceived citizenship status Their body size or weight Their disability or perceived disability None of these Other, please specify: _______________________ I don't know

	During the current school year when you were made aware of instances of bullying, how often have you: (Matrix) Response Options: Always Very often Sometimes Rarely Never (Skip to 14) Items: Reported instances of bullying for disciplinary action Intervened directly
	Were any of the instances of bullying that you reported during the current school year related to the sexual orientation, gender identity, or gender expression of the victim? Yes Possibly No Unsure I did not report any instances of bullying during the current school year
	During the current school year, how many times have you heard a student make negative comments about LGBTQ people? 0 times (Skip to 16) 1 time 2-3 times 4-5 times 6 or more times
	When you heard a student make negative comments about LGBTQ people, how often did you intervene or do something about it? Always Very often Sometimes Rarely Never
	During the current school year, how many times have you heard a staff member make negative comments about LGBTQ people? 0 times (Skip to 18) 1 time 2-3 times 4-5 times 6 or more times
	When you heard a staff member make negative comments about LGBTQ people, how often did you intervene or do something about it? Always Very often Sometimes Rarely Never
	What barriers, if any, have been encountered in your school’s efforts to create safer schools for LGBTQ students? Please select all that apply. Lack of funding or financial resources Lack of time of school personnel Objections by students Objections by parents Objections by teachers Objections by superintendent or other school district administrators Objections by members of the school board Objections by other community members None of these Other, please specify: _______________________ I don´t know
	REFERRALS AND PARTNERSHIPS
	The next set of questions asks about referrals that you have provided, during the current school year, to students in your school. For this study, we are interested in referrals for both the general student population as well as for gay and bisexual males, in particular. We will ask about referrals to: HIV testing services or treatment STD testing services or treatment Other sexual health services such as condoms or HPV vaccine provision Counseling, mental health, psychological, or social services
	Are you aware of a referral protocol that is currently used in your school to link students to community or school-based health services? Yes No (Skip to 21)
	Have you used the referral protocol during the current school year? Yes No

	Did you provide any students with a referral for sexual health or counseling/mental health/psychological/social services this school year? Yes No (Skip to 26) I Do Not Make Referrals (Skip to 26)
	How many total students did you refer to each of the following services? (Matrix) Response options: Number (Drop down menu of numbers ranging from 0-25, with the final option of ‘26 or more’) (if 0, Skip to 26) Items: HIV testing services or treatment STD testing services or treatment Other sexual health services such as condoms or HPV vaccine Counseling, mental health, psychological, or social services
	Of the students that you referred during the current school year, how often did you follow-up to determine if the student accessed the service? (Matrix) Response options: Always Very often Sometimes Rarely Never N/A Items: HIV testing services or treatment STD testing services or treatment Other sexual health services such as condoms or HPV vaccine Counseling, mental health, psychological, or social services

	Of the students that you referred to the following services, how many were males who either: Identified as gay or bisexual OR Told you that they had been engaging in sexual activities with other males (regardless of how they identified)? (Matrix) Response options: Number (Drop down menu of numbers ranging from 0-25, with the final option of ‘26 or more) (if 0, Skip to 26) Items: HIV testing services or treatment STD testing services or treatment Other sexual health services such as condoms or HPV vaccine Counseling, mental health psychological, or social services
	For the male students you referred who identified as gay or bisexual, or told you they had had been engaging in sexual activities with other males (regardless of how they identified), how often did you follow-up to determine if the student accessed the service? (Matrix) Response options: Always Very often Sometimes Rarely Never N/A Items: HIV testing services or treatment STD testing services or treatment Other sexual health services such as condoms or HPV vaccine Counseling, mental health, psychological, or social services
	Did you provide any students with a referral to another school staff member (e.g., a nurse, wellness coordinator, school social worker, counselor, administrator, or teacher) for the purpose of providing access to health, social or psychological services this school year? Yes No (Skip to 30) I Do Not Make Referrals (Skip to 30)

	How many students did you refer to another school staff member (e.g., a nurse, wellness coordinator, school social worker, counselor, administrator, or teacher) for the purpose of providing access to any of the following services? (Matrix) Response options: Number (Drop down menu of numbers ranging from 0-25, with the final option of ‘26 or more’) (if 0, Skip to 30) Items: HIV testing services or treatment STD testing services or treatment Other sexual health services such as condoms or HPV vaccine Counseling, mental health, psychological, or social services
	To which type of school staff member(s) did you most often refer students for each of these services: Please indicate the staff member’s position (e.g., a nurse, wellness coordinator, school social worker, counselor, administrator, or teacher), rather than their name. (Fill-in the blank) Items: HIV testing services or treatment: _________________________ STD testing services or treatment: _________________________ Other sexual health services such as condoms or HPV vaccine: ________ Counseling, mental health, psychological, or social services: _______________________
	Of the students that you referred to another school staff member (e.g., a nurse, wellness coordinator, school social worker, counselor, administrator, or teacher), how many do you believe were gay or bisexual males? (Matrix) Response options: Number (Drop down menu of numbers ranging from 0-25, with the final option of ‘26 or more’) Items: HIV testing services or treatment STD testing services or treatment Other sexual health services such as condoms or HPV vaccine Counseling, mental health, psychological, or social services

	Do your students have access to a school-based health center or Wellness Center? Yes No I don’t know
	Please rate how confident you are in your ability to talk about sexual health with male students who: Identify as gay or bisexual OR Engage in sexual activities with other males (regardless of how they identify) Poor Fair Good Excellent Not sure
	Please rate how confident you are in your ability to make referrals to meet the needs of male students who: Identify as gay or bisexual OR Engage in sexual activities with other males (regardless of how they identify) Poor Fair Good Excellent Not sure
	Are you aware of any organizations in your community that provide sexual health services for males who: Identify as gay or bisexual OR Engage in sexual activities with other males (regardless of how they identify)? Yes No (Skip to 35)
	Please list the organizations by name (don’t worry if you don’t know the exact name—enter as much detail as you recall) __________

	Are you aware of any organizations in your community that provide social services or mental health services for males who: Identify as gay or bisexual OR Engage in sexual activities with other males (regardless of how they identify)? Yes No (Skip to 37)
	Please list the organizations by name (don’t worry if you don’t know the exact name—enter as much detail as you recall) __________
	QUESTIONS ABOUT PROFESSIONAL DEVELOPMENT
	The next questions are about professional development for school personnel. This might include workshops, conferences, continuing education, graduate courses, or any other kind of in-service.
	During the current school year, did you receive professional development in any of the following areas? Please select all that apply. HIV testing services or treatment STD testing services or treatment Other sexual health topics (HPV vaccine, condoms, HIV and STD prevention) Counseling, psychological, or social services Suicide prevention Bullying or harassment Diversity or cultural competency LGBTQ sensitivity Other, please specify _____________________ None of these I don't know
	During the current school year, did you receive professional development related to youth being bullied for any of the following reasons? Please select all that apply. Their gender Their gender expression Their sexual orientation or perceived sexual orientation Their race or ethnicity or perceived race or ethnicity Their family’s income or economic status or perceived income or economic status Their religion or perceived religion Their citizenship status or perceived citizenship status Their body size or weight Their disability or perceived disability None of these Other, please specify: _______________________ I don't know
	QUESTIONS ABOUT POLICIES AT YOUR SCHOOL
	Please answer the following questions about policies and practices in your school to the best of your knowledge. Policies are governing guidelines by which a school district and school buildings are run. Practices are the actual application of an idea or method in the school district or school.

Has your school adopted a policy or practice to offer the following? Please select all that apply.

• Students allowed to be excused from school to receive confidential health or psychological services without being counted absent

• HIV prevention education that includes information about, or skills specifically for, LGBTQ youth

• STD prevention education that includes information about, or skills specifically for, LGBTQ youth

• Sexuality education that acknowledges and validates LGBTQ youth and relationships

• None of these

• I don't know

Has your school adopted a policy or practice that makes condoms available to students?

• Yes

• No (Skip to 42)

• I don't know (Skip to 42)

Are students required to have parental consent to get condoms?

• Yes

• No

• I don’t know

Does your school have a “safer school” or anti-bullying or harassment policy?

• Yes

• No

• I don't Know

SFUSD Supplemental Questions to be integrated in the final format of the survey
1.	During the current school year, how many times have you referred students to the Wellness Center or School-Based Health Center? 0 times 1 time 2-3 times 4-5 times 6 or more times
2.	During the current school year, how many times have you consulted with staff of your school’s Wellness Center or School-Based Health Center? 0 times 1 time 2-3 times 4-5 times 6 or more times
3.	If you intervened [in an instance of bullying], what actions did you take? Please select all that apply. Asked the student who was doing the bullying to stop Educated the bullying student about bullying Referred the student who was doing the bullying to Wellness Center or School-Based Health Center Referred the student who was doing the bullying to the dean or school administration for disciplinary action Referred the students to conflict resolution Implemented restorative practices Other, please specify: __________________
4.	During the current school year, have you ever heard students make harassing statements based on sexual orientation, such as faggot, dyke, and “that’s so gay”? Yes No
5.	During the current school year, have you ever heard teachers or other staff stop other from making harassing statements based on sexual orientation, such as faggot, dyke, and “that’s so gay”? Yes No

Thank you for taking the time to complete this survey. The information you have provided will be very valuable in helping us understand referrals taking place in your school, and also the climate for LGBTQ students. The findings from this survey will be used to help evaluate the success of the project, and inform future project activities.

If you have any questions about your participation in this survey, you can reach the project manager, Catherine Lesesne, at (404) 592 2230 or clesesne@icfi.com.

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