ITT
T
Safe Schools Survey:
Elementary Student Form
- Please fill in bubble completely for each
item using a #2 lead pencil.
- Erase cleanly any mark you wish to change.
- Make no stray marks.
Part 1:
GENERAL
INFORMATION
1. Name of school
I
2. Your sex
5. What is your grade?
a Male a Female
a 3rd a 4th a 5th a 6th
3. How old are you?
6. How long have you been at this school?
a6
a 10
a7
a 11
a8
a 12
a9
a 13
II
II
II
I
4. What is your racial background?
II
II
II
II
II
II
I
a
a
a
a
a
a
a
a
a
a
a
This is my first year
This is my second year
This is my third year
I have been at this school four or more years
White, Non Hispanic
African American
7. How do you typically get to school?
Hispanic
a
a
a
a
Native American
Asian or Pacific Islander
Biracial/Multiracial
Other
School Bus
Walk
Car
Other
Please go to the next page.
T
Safe Schools Survey:
Part 2:
S
U
T T Q
Elementary Student Form
R
V
E
Y
Read each statement carefully.
Mark your answers on the right.
Answer based on this school year.
Strongly Agree(5)
Agree(4)
Neutral(3)
Disagree(2)
Strongly Disagree(1)
1. I feel that I can talk to a teacher or an administrator if I have a problem.
2. I feel safe before and after school while on school grounds.
3. Teachers make sure school rules are followed.
4. Fights among students are common at school.
5. This year I have had something worth $10 or more stolen at school. ................................
6. Some students are regularly beaten up by other students.
7. I have friends at this school.
8. Threats by one student against another are common at school.
9. I have seen a gun at school this year.
10. Teachers listen carefully to what I have to say. ................................................................
11. I feel safe in the lunchroom.
12. I feel safe in the school hallways.
13. I am proud of this school.
14. I feel safe going to and coming from school.
15. Name calling, insults or teasing happen regularly at school. ............................................
16. I have seen a knife at school (not including a cafeteria knife).
17. Teachers enjoy teaching here.
18. Students know what behavior is expected of them.
19. I feel safe in my classrooms.
20. I am learning a lot at this school. .....................................................................................
21. Arguments among students are common at school.
22. Overall, I feel that this school is a safe school.
23. I feel safe in the bathrooms at school.
24. I feel safe on the playground at school.
25. Students enjoy learning here. ..........................................................................................
Thank you for taking the time to complete this questionnaire!
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