ISD/Campus |
|
| 1. Sex |
Male
Female |
| 2. Race or Ethnicity |
White,
non-Hispanic
African-American, non-Hispanic
Native American or Alaskan Native
Hispanic
Asian or Pacific Islander
Other |
| 3. Number of your children who are enrolled on this campus (Select the total number of children at this school) |
0
1
2
3
4
5
6
7
8
9
10
11
12 |
4. Grade(s) of your
child(ren) at this campus
(Select all that apply) |
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th |
| 5. How safe does your child
feel at school? |
very safe
safe
unsafe |
| 6a. Are there particular
places at school where your child(ren) don't feel safe? If so, where are
they? (Select all that apply.) |
classrooms
lunchroom
playground
parking lot
restrooms
school bus
other |
| 6b. Are there certain times
of day when these places are unsafe? (Select all
that apply.) |
Before
school
During
class
During
lunch
After school
Entire
school day
Other |
| 7. This school year, has
your child had something stolen from his/her desk, locker, or other
place at school? |
never
one or two times
three to four times
more than four times |
| 8. This school year, has someone taken money or things directly from your child by using force,
weapons or threats? |
never
one or two
times
three to
four times
more than four times |
| 9. This school year, has
someone physically threatened, attacked, or hurt your child at school? |
never
one or two
times
three to
four times
more
than four times |
| 10a. This school year, has
someone verbally threatened your child at school? |
never
one or two
times
three to
four times
more
than four times |
| 10b. If yes, please specify
where this happened to your child: (Select all that
apply.) |
at school
to and
from school
on a
school bus
at a school-sponsored activity
other |
| 11a. This school year, has
someone made sexual advances or attempted to sexually assault your child
at school? |
never
one or two
times
three to
four times
more
than four times |
| 11b. This school year, has
someone sexually assaulted your child at school? |
never
one or two times
three
to four times
more
than four times |
| 12a. Is there a process in
place for students to report alleged physical, psychological, or sexual
abuse? |
Yes
No |
| 12b. Does the campus
follow-up on reports of alleged abuse? |
Yes
No |
| 13a. During this school
year, has your child talked about seeing a student carrying a weapon at
school? |
Yes
No |
| 13b. If yes, please specify
what kind of weapon your child saw. (Select all that apply.) |
gun
knife
scissors
other |
| 14. During this school year,
how many fights have your child witnessed at school? |
none
one to two
three to five
more than five |
| 15. In your opinion, how
serious are the following problems on this campus:
Vandalism |
don't know
no problem
small
problem
serious problem |
| Gangs |
don't know
no problem
small problem
serious
problem |
| Alcohol Use |
don't know
no
problem
small problem
serious
problem |
| Tobacco Use |
don't know
no problem
small problem
serious
problem |
| Drug Use |
don't know
no problem
small problem
serious
problem |
| Drug Selling |
don't know
no problem
small
problem
serious problem |
| Carrying Weapons |
don't know
no problem
small
problem
serious problem |
| Racial Conflict |
don't know
no problem
small
problem
serious problem |
| Other |
|
| 16. In your opinion, what
are the three major problems at this campus right now? |
|
|
