ISD/Campus
(required)
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)
4. Grade(s) of your
child(ren) at this campus(Select all that apply - Hold the ctrl or command
key to make multiple selections)
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?
