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Safe Schools Student Survey Form
This survey asks about your views on safety and crime on your campus.
Do not write your name on this survey. The answers you give will be kept private.
Choose only one answer for each question, unless you are given other instructions.
1. Sex
2. Race or Ethnicity
3. Grade in School
4. How safe do you feel at school?
5. Are there particular places at school where you don't feel safe? If so, where are they?
(Select all that apply)
classrooms
lunchroom
playground
restrooms
parking lot
school bus
other
6. Are there certain times of day when these places are unsafe?
(Select all that apply)
Before school
During class
During lunch
After school
Entire day
other
7. This school year, have you had something stolen from your desk, locker, or other place at school?
8. This school year, has someone taken money or things directly from you by using force, weapons, or threats?
9. This school year has someone physically threatened, attacked, or hurt you at school?
10. This school year has someone verbally threatened you at school?
11. If yes to 9 and/or 10 above, please specify where this happened to you.
(Select all that apply)
At school
To and from school
On a school bus
At a school sponsored activity
Other
12. This school year has someone made sexual advances or attempted to sexually assault you at school?
13. This school year has someone sexually assaulted you at school?
14. Is there a process in place for students to report alleged physical, psychological or sexual abuse?
15. Does the campus follow-up on reports of alleged abuse?
16. Have you ever seen a student carrying a weapon at school?
17. If yes, please specify what kind of weapon you saw.
(Select all that apply)
Gun
Knife
Box opener
Other
18. During this school year how many fights have you witnessed at your school?
19. How often have you been bullied during your years at this school?
20. How often have you seen others being bullied at this school?
21. When you or someone else was being bullied, what did the bullies do?
(Select all that apply)
Teased
Insulted
Threatened
Played practical jokes
Stole or damaged belongings
Shoved/Kicked/Physically Attacked
22. Why do you think you or others have been bullied?
(Select all that apply)
Because of physical characteristics
Because of race or religion
Because of a physical handicap or learning disability
23. How well do teachers and administrators at this school handle bullying?
24. What more can teachers and administrators do to help stop bullying?
(Select all that apply)
Supervise the playgrounds and halls better
Establish rules against bullying
Enforce rules against bullying and punish bullies
Teach kids how to get along better
25. Have you consumed any alcoholic beverages to include beer, wine, or liquor in the past 12 months,without the permission of your parent(s) or guardian(s)?
26. Have you used any illegal drugs or medications to include marijuana, cocaine, crack, ecstasy, hallucinogens, or heroine in the past 12 months without the permission of your parent(s) or guardian(s)?
27. If you answered yes to 25/26 above, how much?
28. Have you used any inhalants to include freon, ether, spray paint, whiteout, fingernail polish, glue, hairspray, or any other type of chemical that produces vapors that are mood altering in the past 12 months?
29. If you answered yes to 28, how much?
30. In your opinion how serious are the following problems at school?
Vandalism
Gangs
Alcohol Use
Tobacco Use
Drug Use
Drug Selling
Carrying Weapons
Racial Conflict
Other
(Please type in your answer)
31. In your opinion what are the three major problems at school right now?
(Please type in your answer)
32. Please indicate the earliest age you have used any of the following substances by clicking on the appropriate age.
Alcohol
Marijuana
Tobacco
Steroids
Rohypnol
Downers
Uppers
Hallucinogens
Crack/Cocaine
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