Student

Survey

Student	Name:

___________________________________

(Label	provided	by	survey	firm)

Student ID:

___________________________________

(Label	provided	by	Survey	Firm)

We	would	like	to	ask	you	some	questions	about	yourself	and	your	school.		We	are	going	to	read all	questions	aloud	to	

you.	Please	follow	along	in	your	booklet.	You	do	not	have	to	answer	any	question	you	do	not	want	to	answer.	Your	

participation	in	this	survey	is	completely	voluntary,	but	your	answers	will	be	very	helpful for	improving	your	

school.	Your	answers	will	be	kept	private and	the	surveys	will	be	kept	in	a	safe	place;	only	researchers	working	on	this	

project	will	see	them.	Teachers,	parents,	and	others	in	your	community	will	not	have	access	to	your	responses	to	the	

questions.

Please	do	not	write	your	name	inside	this	form	or	the	answer	sheet.		Do	not	identify	yourself	in	any	other	way.		

Write	clearly	and	fill	in	circles	with	a	pencil	or	blue/black	ink	pen.	Mark	only	one	answer	for	each	question.		

Once	you	have	answered	all	of	the	questions,	please	close	the	booklet	and	wait	for	the	person	assisting	with	this	study	

to	collect	it	from	you. If		you	have	any	questions	during	the	survey,	please	raise	your	hand.	

Thank	you	for	taking	time	to	answer	these	questions!

Multi-Tiered Systems of 

Support for Behavior 

(MTSS-B)
Page	1

A1. How much do you agree or disagree with each of these statements about the students in your class?

Mark one answer for each row.

Disagree

a lot

Disagree

Don’t 

agree or 

disagree

Agree

Agree 

a lot

a

Students in my class are willing to go out of their way to 

help someone.

1 2 3 4 5

b My classmates care about my work just as much as 

their own.

1 2 3 4 5

c My class is like a family. 1 2 3 4 5

d Students in my class don’t really care about each other. 1 2 3 4 5

e A lot of students in my class like to put others down. 1 2 3 4 5

f Students in my class help each other learn. 1 2 3 4 5

g

Students in my class help each other, even if they are 

not friends.

1 2 3 4 5

h Students in my class don’t get along very well. 1 2 3 4 5

i Students in my class just look out for themselves. 1 2 3 4 5

j Students in my class are mean to each other. 1 2 3 4 5

k When I’m having trouble with my schoolwork, at least 

one of my classmates will try to help.

1 2 3 4 5

l Students in my class treat each other with respect. 1 2 3 4 5

m Students in my class work together to solve problems. 1 2 3 4 5

n When someone in my class does well, everyone in the 

class feels good.

1 2 3 4 5
Page	2

A2. How much do you agree or disagree with each of these statements about the time you spend in class?

Mark one answer for each row.

Disagree

a lot

Disagree

a little

Agree

a little

Agree 

a lot

a

I try hard to do well in school. 1 2 3 4

b When I’m in class, I join in on class discussion. 1 2 3 4

c

In class, I work as hard as I can. 1 2 3 4

d

I pay attention in class. 1 2 3 4

e When I’m in class, I listen very carefully. 1 2 3 4

f When I’m in class, I pretend like I’m working. 1 2 3 4

g

I don’t try very hard in school. 1 2 3 4

h

In class, I only work as much as I have to so that I don’t 

get in trouble.

1 2 3 4

i When I’m in class, I think about other things. 1 2 3 4

j When I’m in class, my mind wanders. 1 2 3 4

A3. We want to know how you feel about your school. Please tell us if you agree or disagree with each statement. Please 

read each sentence carefully before answering.

Mark one answer for each row. Disagree Agree

a

Some students at my school often say that they will hit 

or beat others.

1 2

b Students at my school often get hurt in school. 1 2

c My school is usually very noisy. 1 2

d My school is usually clean and tidy. 1 2

e Some students carry guns and knives in my school. 1 2

f Students at my school fight a lot. 1 2

g Students at my school call each other bad names. 1 2
Page	3

A4. We want to know how you feel about your school. Please tell us if you agree or disagree with each statement. Please 

read each sentence carefully before answering.

Mark one answer for each row. Disagree Agree

a

At my school, all students are treated the same, even if 

their parents are rich or poor.

1 2

b Everyone is treated equally well at my school. 1 2

c At my school, students of all races are treated the same. 1 2

d At my school, boys and girls are treated equally well. 1 2

e At my school, teachers are fair to everyone. 1 2

A5. Based on your experiences at school in the past two weeks, how much do you agree or disagree with each of these 

statements about your school?

Mark one answer for each row.

Disagree

a lot

Disagree

a little

Agree

a little

Agree 

a lot

a Students feel safe at this school. 1 2 3 4

b

I feel afraid that someone will hurt me at this school. 1 2 3 4

c

Other students are afraid that someone will hurt them 

at school.

1 2 3 4

d Students feel that someone will tease them at school. 1 2 3 4

e

Students feel afraid that someone will bully them in this 

school.

1 2 3 4

A6a. Read the statement below and choose the answer that describes how you feel.

Mark only one answer.

It’s really 

wrong

It’s sort of 

wrong

It’s sort of 

okay

It’s perfectly 

okay

a

In general, it is wrong to hit people. 1 2 3 4

A6b. Read the statement below and choose the answer that describes how you feel.

Mark only one answer.

It’s perfectly 

okay

It’s sort of 

okay

It’s sort of 

wrong

It’s really 

wrong

b

If you’re angry, it is OK to say mean things to 

other people.

1 2 3 4
Page	4

A6c. Read the statement below and choose the answer that describes how you feel.

Mark only one answer.

It’s perfectly 

okay

It’s sort of 

okay

It’s sort of 

wrong

It’s really 

wrong

c

In general, it is OK to yell at others and say bad 

things.

1 2 3 4

A6d. Read the statement below and choose the answer that describes how you feel.

Mark only one answer.

It’s perfectly 

okay

It’s sort of 

okay

It’s sort of 

wrong

It’s really 

wrong

d

It is usually OK to push or shove other people 

around if you’re mad.

1 2 3 4

A6e. Read the statement below and choose the answer that describes how you feel.

Mark only one answer.

It’s really 

wrong

It’s sort of 

wrong

It’s sort of 

okay

It’s perfectly 

okay

e

It is wrong to insult other people. 1 2 3 4

A6f. Read the statement below and choose the answer that describes how you feel.

Mark only one answer.

It’s really 

wrong

It’s sort of 

wrong

It’s sort of 

okay

It’s perfectly 

okay

f

It is wrong to take it out on others by saying 

mean things when you’re mad.

1 2 3 4

A6g. Read the statement below and choose the answer that describes how you feel.

Mark only one answer.

It’s really 

wrong

It’s sort of 

wrong

It’s sort of 

okay

It’s perfectly 

okay

g

It is generally wrong to get in physical fights 

with others

1 2 3 4

A6h. Read the statement below and choose the answer that describes how you feel.

Mark only one answer.

It’s perfectly 

okay

It’s sort of 

okay

It’s sort of 

wrong

It’s really 

wrong

h

In general, it is OK to take your anger out on 

others by using physical force

1 2 3 4
Page	5

A7. Please read each sentence and think about yourself. Then answer whether it is not true for you, a little true for you, a lot 

true for you, or very true for you.

Mark one answer for each row. Not true for 

you

A little true 

for you

A lot true for 

you

Very true for 

you

a

I pay attention when others present their ideas. 1 2 3 4

b

I ignore others who act up in class. 1 2 3 4

c

I do what the teacher asks me to do. 1 2 3 4

d

I do my work without bothering others. 1 2 3 4

e

I follow school rules. 1 2 3 4

f

I pay attention when the teacher talks to the class. 1 2 3 4

g

I work well with my classmates. 1 2 3 4

h

I stay calm when I am teased. 1 2 3 4

i

I stay calm when people point out my mistakes. 1 2 3 4

j

I try to find a good way to end a disagreement. 1 2 3 4

k

I stay calm when dealing with problems. 1 2 3 4

l

I stay calm when others bother me. 1 2 3 4

m

I stay calm when I disagree with others. 1 2 3 4
Page	6

A8. Please read each sentence and think about yourself. Then answer whether it is not true for you, a little true for you, a 

lot true for you, or very true for you.

Mark one answer for each row. Not true for 

you

A little true 

for you

A lot true for 

you

Very true for 

you

a

I make other people do what I want them to do. 1 2 3 4

b

I often do things without thinking. 1 2 3 4

c

I swear or use bad words. 1 2 3 4

d

I find it’s hard to focus on what I am doing. 1 2 3 4

e

I hurt people when I am angry. 1 2 3 4

f

I have temper tantrums. 1 2 3 4

g

I lie to others. 1 2 3 4

h

I often get distracted. 1 2 3 4

i

I do not let others join my group of friends. 1 2 3 4

j

I find it hard to sit still. 1 2 3 4

k

I cheat when playing games. 1 2 3 4

l

I make careless mistakes in schoolwork. 1 2 3 4

m I try to make others afraid of me. 1 2 3 4

n

I break things when I’m angry. 1 2 3 4

o

I talk back to adults. 1 2 3 4

p I waste a lot of time 1 2 3 4

q I say things to hurt people’s feelings 1 2 3 4

r I fight with others 1 2 3 4

s I break the rules 1 2 3 4
9a. Does your school have expectations that 

everyone is supposed to follow (that is, how all 

students should behave)?

1 Yes (GO TO 9b)

2 No (GO TO 10a)

3 Not Sure (GO TO 10a)

9b. Are the expectations the same in different parts 

of the school? For example, are they the same in 

your classroom, the playground and the 

hallways?

1 Yes

2 No

3 Not Sure

9c. How many expectations does your school have?

1 None

2 Less than 3 expectations

3 3-5 expectations

4 More than 6 expectations

5 Not Sure

9d. Did your teacher teach you the school 

expectations?

1 Yes (GO TO 9e)

2 No (GO TO 10a)

3 Not Sure (GO TO 10a)

9e. Did your teacher teach what the school 

expectations mean in different places in the 

school, such as the classroom, cafeteria, and 

hallway?

1 Yes 

2 No 

3 Not Sure

10a. Has your teacher used a token system

(proctors will be trained to replace the word 

“token” with school-specific reward system if 

there is one) in your classroom?

1 Yes

2 No

3 Not Sure

10b. Have you ever received a token (proctors will 

be trained to replace the word “token” with 

school-specific reward system if there is one)

in your classroom?

1 Yes

2 No

3 Not Sure

10c. Did your teacher play the Positive Behavior 

Game in your classroom?

1 Yes

2 No

3 Not Sure

YOU ARE FINISHED WITH 

THIS SURVEY
Page	8