# Student Survey

**Student	Name :** 

**___________________________________**

(Label	provided	by	survey	firm) **Student ID** **:**

**___________________________________**

(Label	provided	by	Survey	Firm) We	would	like	to	ask	you	some	questions	aboutyourself	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	que** **stion	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 andthe	surveys	will	be	kept	in	a	safe	place;	onlyresearchers	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	a ny	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 tocollect	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 5Page 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 2Page 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 p** **ast 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.** 

### Markonlyone 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.**  

### Markonlyone 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 4Page4 **A6c. Read the statement below and choose the answer that describes how you feel.**  

### Markonlyone 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.**  

### Markonlyone 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.** 

### Markonlyone 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.**  

### Markonlyone 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.** 

### Markonlyone 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.** 

### Markonlyone 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 4Page 5 **A7.** Please read each sentence and think aboutyourself. Then answerwhether 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 4Page 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 Lessthan 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


# YO**U ARE FINISHED WITH THIS SURVEY** Page8