Back to School Survey 2015

This survey is for my intervention classes.
Name (optional): 


A red asterisk (*) indicates required questions.

  1. Enter your school email address. *


  1. Which class are you in?  *


  1. Select the option which best describes your feeling of safety at Worthington Middle School? (safety is name calling, bullying, threats, fights, being sworn at, unwanted physical touch, theft . . . .*
    I feel safe.
    I am mostly safe.
    I have had a few minor safety issues.
    I often worry about safety.
    I do not feel safe.


  1. Do you feel that most teachers in this building are trying to help you build your academic skills?*
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. Does Worthington Middle School have high expectations for all students to do better academically, socially, and physically?
    *
      1 2 3 4 5  
    Strongly agree   Strongly disagree


  1. Select the option which best describes the interest level of the classes you have had.*
    All of my classes have been interesting.
    The majority of my classes have been interesting.
    About half of my classes have been interesting.
    I have had only a few classes I found interesting.
    Most of my classes have been boring.


  1. Rate your ability to self-regulate in the areas listed.*

            1 2 3 4 5      
      Emotional Control Excellent  Poor  
      Behavior Control Excellent  Poor  
      Language Control Excellent  Poor  
      Impulse Control (Blurting) Excellent  Poor  
      Social Control (relations with classmates) Excellent  Poor  


  1. Which best describes your academic expectations.  *


  1. Are you treated fairly by staff and the principals if there is a concern about your behavior.  *


  1. What is your daily screen time in hours. Count all time in front of a screen - computers, TV, Tablets, Phones, Devices, other electronic devices. . .*


  1. Who do you trust or can turn to for help if you have a serious problem. You may check as many choices that apply.*
    The principals
    There is a teacher or teachers that I trust.
    The counselor
    The nurse
    One of the school secretaries
    a para
    one of the cooks
    my bus driver
    a coach
    a custodian
    There is no one that I trust.


  1. Which describes how you deal with setbacks (failures).  *


  1. Check the hobbies and interests that apply to you. You can have several choices.*
    Playing sports
    Reading books
    Texting
    Watching TV, movies, Netflix
    Social Media
    Surfing the Web
    Snap Chatting
    Going over to a friend's house
    Having friends over
    Playing video games: Xbox, Nintendo. . .
    biking
    drawing or doing other art


  1. Complete the statement. My favorite sport is *


  1. Complete the statement. My favorite book is *


  1. Complete the statement. My favorite song is *


  1. Complete the statement My favorite movie is *


  1. Complete the statement. My favorite television show is *


  1. Complete the statement. A person I admire is *


  1. Complete the statement. My best friends are *


  1. Complete the statement. My favorite sport's team is *


  1. You were referred to this class because of low scores on your MCAs and referrals from your last year's classroom teachers. Did you realize that your reading / math was at that low of a level, and how do you feel about that?*


  1. This question is completely confidential. It will be shared with no one. Mark any of these traumatic events that you may have experienced this past year.*
    death in the family
    family member arrested
    family member deported
    serious illness of a family member
    divorce
    homelessness or having to move multiple times
    teen pregnancy in the family
    family member dropped out of school
    Parent lost their job
    victim of bullying or harassment
    family member with drug problems
    family member with alcohol problems
    I haven't experienced any traumatic problems.


  1. Put these important skills in order for what you are strongest in to what you are weakest in. 1 is the strongest. 9 is the weakest. Each number is used once.*
        1 2 3 4 5 6 7 8 9
    being curious to learn new things  
    communication skills  
    persisting - not quitting when things are hard  
    resilience - not giving up, working harder after a failure  
    being accurate, doing high quality work  
    asking questions or getting help when you need it  
    controlling your impulses  
    listening and listening with understanding  
    taking responsible risks  


  1. Select two of the teenage challenges that you would like more information or help on this year*
    Being able to see problems from other points of view.
    Developing a moral value system.
    Managing more responsibilities as I mature.
    Dealing with physical and mental challenges that come with puberty.
    Being a better decision maker.
    Dealing with all these intense emotions.
    I want healthy, supportive friendships.
    Dealing with changing relationships between myself, parents, and friends.


  1. Do you have any other concerns that you want to share with the instructor? These will be dealt with privately.


  1. You were referred to this class because of low scores on your MCAs and referrals from your last year's classroom teachers. Did you realize that your reading / math was at that low of a level. Check any of these reasons for performing poorly that may apply to you.
    I don't pay attention in my classes.
    I am not a good test taker.
    School is not a priority for me.
    I get really nervous about taking tests.
    I don't do a lot of homework for my classes
    I do not like to read.
    I cannot read multiple sysyllabe (long) words.
    I cannot remember much of what I have read.
    I rarely wear my glasses.
    I start books, but I do not usually finish them.
    I do not go back and reread when I have lost meaning.
    I do not know my multiplication facts.
    I do not know my division facts.
    I can't do simple math problems fast.
    After reading a math problem, I am often unsure of what to do.
    I make a lot of simple calculation mistakes, or I do not check my answer for accuracy.





Mr. Burns
Worthington Middle School
Worthington, MN