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Student Needs Assessment Questionnaire

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School Name: __________________________________

Please take some time to complete this questionnaire. It will take approximately 45 - 60 minutes to complete. Your responses will provide important information to help your school plan ways to support your health and well-being.

Thank you for helping your school become a healthier, safer, and more caring learning environment.

Confidential

Purpose of the Survey

This survey provides an opportunity to share your thoughts on what you feel is needed to ensure that you and your school can be as safe, healthy and supportive as possible.

You do not have to fill out this survey if you do not want to. However, everyone’s views are important. Please understand that this questionnaire is completely confidential.

|Do not write your name on the questionnaire. |

When you are finished, place your questionnaire in the envelope or box provided. All questionnaires will be compiled together so individual questionnaire will not be identified. The results of all questionnaires will be added together and reported back to the school without any individual student ever being identified.

Instructions

• Please read each question carefully and answer as accurately as you can.

• There are two types of questions. One type requires you to look at the answer key provided with the question to choose your response. The other type of question requires you to place either a ( or an X in the box beside your response. For example:

1. Answer each question by choosing a number from the answer key and writing it in the space provided.

| |
|Example: Below is a list of unpleasant conditions that could occur at school, work or play. |
|For each condition listed below, choose the response from the answer key that you think best |
|describes to what extent these conditions concern you at school. |
| |
|Answer Key |
|1 = Does not occur at my school |
|2 = Very little concern |
|3 = Somewhat concerned |
|4 = Very concerned |
| |
|a. 1 Too much heat or cold |
|b. 4 Bad air (stuffy, not enough air, mold, smells, etc.) |
|c. 3 Too much noise or vibration |

2. Answer each question by placing a ( or an X in the box provided.

| |
|Example: What gender are you? |
| |
|1. ( Male |
|2. ( Female |
| |

• Use a pencil so you can erase any answers you want to change.

• When you are finished, place your questionnaire in the envelope or box. Your answers are completely confidential.

• Please remember, no one will use this information to identify you.

Your Background

In order to understand the information you are about to provide, we need to ask you some questions about yourself. This will help us understand the specific needs at the school.
Please remember, no one will use this information to identify you.

1. How old are you? Please check the one response that best describes you.

1. ( Under 14 2. ( 14 -15 3. ( 16 -17 4. ( 18 -19 5. ( 20+

2. What gender are you? Please check the one response that best describes you.

1. ( Male 2. ( Female

3. Please indicate at what grade level you are taking most of your courses. Please check the one response that best describes you.

|Grade |Grade (Quebec) |
|1. ( Grade 9 |5. ( Secondary 3 |
|2. ( Grade 10 |6. ( Secondary 4 |
|3. ( Grade 11 |7. ( Secondary 5 |
|4. ( Grade 12 |8. ( CEGEP 1 |
| |9. ( CEGEP 2 |

4. In your opinion, what kind of grades (marks) do you usually get? Please check the one response that best describes you.

1. ( Not very good 2. ( Fair 3. ( Average 4. ( Very good 5. ( Excellent

5. What do you think you will be doing when you finish high school? Please check the one response that best describes you.

1. ( University 2. ( Community College 3. ( CEGEP - General Program 4. ( CEGEP - Professional program 5. ( Technical or Business College 6. ( Apprenticeship 7. ( Job/working 8. ( Armed Forces 9. ( Looking for work 10. ( Uncertain

|* Note when we ask about your ‘father’ or ‘mother’ or your ‘parents’ we refer to the one(s) you live with most of the time; it |
|could be parent(s), stepparent(s), foster parent(s),or guardian(s). |

6. People live in different types of families. Sometimes people live with just one parent, sometimes they live with each parent but in different homes, or sometimes they live in different situations. If you live in only one home/family, please fill out column A. If you live in two homes/families, please fill in column A for the home you live in most of the time, and column B for your second home/family (do not include cottage or holiday home.)

|Column A |Column B |
|If you live in only one home, |If you also live at a second home sometimes |
|or where you live most of the time, |(do not include cottage or holiday home), |
|please check all the people you live with. |please check all the people you live with. |
| | |
|1. ( Mother |13. ( Mother |
|2. ( Father |14. ( Father |
|3. ( Stepmother |15. ( Stepmother |
|4. ( Stepfather |16. ( Stepfather |
|5. ( Foster family or group home |17. ( Brothers (include step, half |
|6. ( Brothers (include step, half |and foster brothers) |
|and foster brothers) |18. ( Sisters (include step, half |
|7. ( Sisters (include step, half |and foster sisters) |
|and foster sisters) |19. ( Grandmother |
|8. ( Grandmother |20. ( Grandfather |
|9. ( Grandfather |21. ( Other relatives |
|10. ( Other relatives |22. ( Other people |
|11. ( Other people | |
|12. ( I live on my own | |

7. Are you responsible for anyone at home on either a part time or full time basis (e.g. a sick or elderly relative, parent, a younger brother or sister, child)? Please check the one response that best describes you.

1. ( Yes 2. ( No

8. How long have you lived in Canada? Please check the one response that best describes you.

1. ( Since birth 2. ( More than 10 years 3. ( 5-10 years 4. ( Less than 5 years

Your Health

9. In your opinion, how would you describe your health? Please check the one response that best describes you.

1. ( Poor 2. ( Fair 3. ( Good 4. ( Very good 5. ( Excellent

10. A. Do you have a disability, long-term illness (e.g. leukemia) or chronic condition (e.g. diabetes, asthma)? Please check the one response that best describes you.

1. ( Yes 2. ( No

B. If you have a disability, long-term illness or chronic condition, please check the relevant category below. Please check all responses that apply to you.

1. ( I do not have such a condition. 2. ( Learning disability 3. ( Physical disability 4. ( Emotional disability 5. ( Allergies (food) 6. ( Allergies (respiratory) 7. ( Asthma 8. ( Diabetes 9. ( Other (please specify): ______________________________________

C. Does your disability, long-term illness or chronic condition affect your attendance and participation at school? Please check the one response that best describes you.

1. ( I do not have such a condition 2. ( Yes 3. ( No

11. What would you like to do in the next year to improve or maintain your health? Please check all the responses that apply to you.

1. ( Drink less coffee or tea 2. ( Eat healthier foods 3. ( Be more physically active 4. ( Remove a major source of worry, nerves or stress from my life 5. ( Learn to cope better with worry, nerves or stress 6. ( Change schools 7. ( Change my home situation 8. ( Quit smoking or smoke less 9. ( Drink less alcohol 10. ( Cut down on painkillers, sleeping or calming medications 11. ( Cut down on other medications 12. ( Cut down on non-medical drug use 13. ( Lose weight 14. ( Gain weight 15. ( Get medical treatment 16. ( Skip fewer meals 17. ( Learn to be more assertive 18. ( Learn to control anger (better) 19. ( Learn to communicate (better) 20. ( Learn to deal with relationships 21. ( Learn to manage time (better) 22. ( Learn to manage money (better) 23. ( Deal/cope with an eating disorder 24. ( Deal/cope with bullying 25. ( Deal/cope with violence 26. ( Nothing 27. ( Other (please specify): ______________________________________
12. What is stopping you from making this change? Please check all the responses that apply to you.

1. ( Nothing 2. ( Problem isn’t serious, there’s no rush 3. ( My boyfriend/girlfriend is not supportive 4. ( Not enough facilities, equipment, gear 5. ( Difficult situation at home 6. ( Not enough time 7. ( Not enough energy 8. ( Not enough money 9. ( I’m too depressed (sad) 10. ( I don’t know how to get started 11. ( No encouragement or help from family and friends 12. ( No encouragement or help from school 13. ( It is too hard 14. ( I don’t want to change my ways 15. ( I’m not sure I really can make a difference 16. ( I have too much stress right now 17. ( I’m afraid of the unknown (future) 18. ( I’m unsure of myself (lack self-confidence) 19. ( I don’t know what is stopping me 20. ( It is not important to me 21. ( I don’t feel like it 22. ( Other (please specify): ______________________________________

13. For each symptom below, choose your response from the answer key and place the corresponding number of your answer in the line beside each symptom. For example, if your answer for headache is seldom or never, place the number 1 on the line beside headache.

|ANSWER KEY |
|1 = seldom or never |
|2 = about once every month |
|3 = about once every week |
|4 = more than once a week |
|5 = most days |

In the last six months, how often have you felt the following?

a. ___ Headache b. ___ Stomach-ache c. ___ Backache d. ___ Feeling low (depressed, sad) e. ___ In a bad mood (irritable, cranky) f. ___ Feeling nervous (uneasy) g. ___ Trouble getting to sleep h. ___ Feeling dizzy

14. For each statement below, choose your response from the answer key and place the corresponding number of your answer on the line beside each statement.

|ANSWER KEY |
|1 = seldom or never |
|2 = about once every month |
|3 = about once every week |
|4 = more than once a week |
|5 = most days |

In the last six months, how often were you:

a. ___ So hungry at school that you couldn’t concentrate on your school work b. ___ So stressed out or worried at school that you couldn’t concentrate on your school work c. ___ So tired at school that you couldn’t concentrate on your school work d. ___ So physically or mentally tired at the end of the school day that you couldn’t enjoy your time away from school

15. How many hours do you usually sleep at night? Please check the one response that best describes you.

1. ( 0 to 4 hours 2. ( 5 to 6 hours 3. ( 7 to 8 hours 4. ( 9 hours or more

16. How often do you have trouble sleeping? Please check the one response that best describes you.

1. ( More than once a week 2. ( Once a week or less 3. ( Never
Your Feelings

17. For each statement below, choose the response from the answer key that best describes yourself. Place the corresponding number on the line beside each statement.

|ANSWER KEY |
|1 = strongly disagree |
|2 = disagree |
|3 = not sure |
|4 = agree |
|5 = strongly agree |

Please indicate how you feel about the following statements.

a. ___ I have trouble making decisions b. ___ I have confidence in myself (I am sure of myself) c. ___ I would change how I look, if I could d. ___ I have usually found that what is going to happen will happen, regardless of my plans e. ___ I usually behave according to my beliefs f. ___ My life is full of meaning and purpose g. ___ On the whole, it seems to me that things turn out the way they should h. ___ I like myself i. ___ My parents understand me j. ___ I have a happy home life k. ___ I am often sorry for the things I do l. ___ I often wish I were someone else m. ___ My parent(s) expect too much of me n. ___ My parents trust me o. ___ I have a lot of arguments with my parent(s) p. ___ There are times when I would like to leave home q. ___ I often have a hard time saying “no” r. ___ What my parent(s) think of me is important s. ___ I often have trouble expressing my feelings

Your Work

18. Do you have a part time job? Please check the one response that best describes you.

1. ( No 2. ( Yes, less than 10 hours a week 3. ( Yes, from 10 to 17 hours a week 4. ( Yes, more than 17 hours a week

19. Why do you have a part time job? Please check all the responses that apply to you.

1. ( I do not have a part time job 2. ( To help support myself (basic housing, food) 3. ( To help make money for my own use (spending money) 4. ( To help support my family 5. ( To pay for my future education 6. ( Other (please specify): ______________________________________

Your Family

|* Note that when we ask about your ‘father’ or ‘mother’ or your ‘parents’ we refer to the one(s) you live with most of the time; |
|it could be parent(s), stepparent(s), foster parent(s),or guardian(s). |

‘Family’ can give us support when we are stressed or worried and help us work through problems when we are faced with difficult decisions, or can add to our stress if we are constantly worried about their reaction. Family support is an important influence on health and well being.

20. Which of the following statements best describes the family that you currently live with most of the time? Please check the one response that best describes your family.

1. ( An exceptionally close family that enjoys each other’s company and does many things together 2. ( A fairly close family that gets along more often than not and where things run smoothly, most of the time 3. ( An indifferent family, members do not interact with each other, rarely do things together as a group; members are notably cool towards each other (not very concerned about each other) 4. ( An unhappy family, usually arguing or fighting or not speaking to each other; members avoid each other when possible

21. For each statement below, choose the response from the answer key that you think best describes your parent(s)/caregiver(s). If your mother and father live in different places, answer for the parent/caregiver or household with whom you live most of the time.

|ANSWER KEY |
|1 = never |
|2 = rarely |
|3 = sometimes |
|4 = often |
|5 = always |
|6 = I live on my own/independently |

a. ___ If I have problems at school, my parent(s)/caregiver(s) are ready to help me b. ___ My parent(s)/caregiver(s) are willing to come to school to talk with teachers c. ___ My parent(s)/caregiver(s) encourage me to do well at school d. ___ My parent(s)/caregiver(s) expect too much of me at school
Your School Environment

22. How do you currently feel about school? Please check the one that best describes you.

1. ( I like it a lot 2. ( I think its okay 3. ( I don’t like it very much 4. ( I don’t like it at all

23. In the last complete term/semester, about how many days were you away from school? Please check the one that best describes you.

1. ( None 2. ( 1 to 5 days 3. ( 6 to 10 days 4. ( 11 to 15 days 5. ( 16 to 20 days 6. ( More than 20 days

24. For which of the following reasons were you away from school? Please check all the reasons that apply to you.

1. ( I was at a doctor/dentist appointment 2. ( I was sick, injured or disabled 3. ( I was working 4. ( I was looking after someone at home (a child, parent, relative) 5. ( I was having a hard time at school 6. ( I was thrown out of home 7. ( I ran away from home 8. ( I was afraid of someone or some people at school 9. ( I was suspended from school 10. ( I was skipping school 11. ( I was on an extended family vacation 12. ( Other (please specify): ______________________________________

25. How many times did you skip class(es) or school this term? Please check the one response that best describes you.

1. ( 0 2. ( 1 time 3. ( 2 times 4. ( 3 times 5. ( 4 or more times

26. Have you ever quit school (dropped out), or have you ever been suspended? Please check the one response that best describes you.

1. ( No 2. ( Yes, I dropped out 3. ( Yes, I was suspended
Physical Environment

27. Below is a list of unpleasant conditions that occur at school. For each condition listed below, choose the response from the answer key that you think best describes to what extent these conditions concern you at school.

|ANSWER KEY |
|1 = does not occur at my school |
|2 = very little concern |
|3 = somewhat concerned |
|4 = very concerned |

a. ___ Too much heat or cold

b. ___ Bad air (stuffy, not enough air, mold, smells, etc.)

c. ___ Too much noise or vibration

d. ___ Poor work space or not enough work space

e. ___ Poor lighting (too little, too much, etc.)

f. ___ Being around students who are under the influence of drugs or alcohol

g. ___ Dirt, litter or mess in work or play areas (e.g. classrooms, portables, washrooms, playgrounds, gyms, change rooms)

h. ___ Being around students with weapons

i. ___ Risk of physical injury (like getting beaten up)

j. ___ Risk of eyestrain

k. ___ Dangerous chemicals

l. ___ Infectious diseases

m. ___ Unsafe equipment or machinery

n. ___ X-rays, other electro-magnetic radiation, or computer/video display terminals

o. ___ Overcrowding (too many people)

Social Environment

28. Please read each answer below carefully. For each statement, choose the response from the answer key that you think best describes your school.

|ANSWER KEY |
|1 = strongly disagree |
|2 = disagree |
|3 = not sure |
|4 = agree |
|5 = strongly agree |

a. ___ In our school the students take part in making the rules b. ___ The students are treated too severely/strictly in this school c. ___ The rules in this school are fair d. ___ Our school is a nice place to be e. ___ I feel I belong at this school f. ___ Our school is a place where the health of people is important

29. Please read each statement below carefully. For each statement, choose the response from the answer key that you think best describes your teachers. If you have only one teacher, think of this person when you answer the questions.

|ANSWER KEY |
|1 = strongly disagree |
|2 = disagree |
|3 = not sure |
|4 = agree |
|5 = strongly agree |

a. ___ I am encouraged to express my own views in class b. ___ Our teachers treat us fairly c. ___ When I need extra help I can get it d. ___ My teachers show an interest in me as a person e. ___ My teachers expect too much of me at school

30. Please read each statement carefully. For each statement, choose the response from the answer key that you think best describes the students in your classes.

|ANSWER KEY |
|1 = strongly disagree |
|2 = disagree |
|3 = not sure |
|4 = agree |
|5 = strongly agree |

a. ___ The students in my classes enjoy being together b. ___ Most of the students in my class(es) are kind and helpful c. ___ Our students accept me as I am

31. Do you feel safe at school? Please choose one response that best describes you.

1. ( Never 2. ( Rarely 3. ( Sometimes 4. ( Often 5. ( Always

Below are some questions about bullying. A person is being bullied when another person or group of people says or does nasty and unpleasant things to him/her such as taunting, threatening, hitting, and stealing.
It is also bullying when a person is teased repeatedly in a way he/she doesn’t like. Bullying may also occur indirectly by causing a person to be socially isolated through intentional exclusion. It is not bullying when two students about the same strength quarrel or fight.

32. How often have you been bullied in school this term/semester? Please check the one response that best describes you.

1. ( I have not been bullied at school 2. ( Once or twice 3. ( Sometimes 4. ( About once a week 5. ( Several times a week

33. How often has someone bullied you in school this term/semester in the ways listed below? For each situation listed below, choose the response from the answer key that most closely describes your situation.

|ANSWER KEY |
|1 = I have not been bullied in this way |
|2 = once or twice |
|3 = about once a week |
|4 = more than once a week |

a. ___ Hit, slapped or pushed you b. ___ Threatened you c. ___ Spread rumours or lies about you d. ___ Made sexual jokes, comments or gestures to, or about, you e. ___ Purposely left you out of activities, isolated you f. ___ Took or stole personal items from you g. ___ Made fun of (taunted) you

34. For each of the four situations listed below, choose the response from the answer key that most closely describes your situation.

|ANSWER KEY |
|1 = I have not been bullied for this reason |
|2 = once or twice |
|3 = about once a week |
|4 = more than once a week |

How often has someone bullied you in school this term/semester for the reasons listed below?

a. ___ Made fun of you because of your religion or race b. ___ Made fun of you because of the way you look or talk c. ___ Made fun of you because of your disability d. ___ Made fun of you because of your sexual orientation

35. If you have been bullied in school this term/semester, who usually bullies you? Please check the one response that best describes you.

1. ( I have not been bullied 2. ( One boy 3. ( One girl 4. ( A group of boys 5. ( A group of girls 6. ( A group of boys and girls 7. ( Other (please specify): ______________________________________

36. For each of the reactions listed below, choose the response from the answer key that most closely describes your reaction.

|ANSWER KEY |
|1 = I have not been bullied |
|2 = Yes |
|3 = No |

If you have been bullied this term/semester, how did you/do you usually react?

a. ___ Fight b. ___ Shout (yell) at the others c. ___ Do nothing and wait until they calm down d. ___ Look for somebody to help me e. ___ Try to get away f. ___ Go to a teacher g. ___ Go to my parents h. ___ Go to other adults i. ___ Nothing, there isn’t anything that can be done j. ___ Other (please specify): ______________________________________

37. Did the bullying stop? Please check the one response that best describes you.

1. ( I have not been bullied 2. ( Yes 3. ( No

38. How often have you taken part in bullying other students in school this term/semester? Please check the one response that best describes you.

1. ( I have not bullied others at school 2. ( Yes, once or twice 3. ( Yes, sometimes 4. ( Yes, about once a week 5. ( Yes, several times a week
Personal Resources

39. When you are worried, upset, or under stress, how many people can you really count on to understand how you are feeling? Please check one answer in each of the following sections (At Home, At School, Elsewhere).

At Home 1. ( No one 2. ( 1 or more people At School 1. ( No one 2. ( 1 or more people Elsewhere 1. ( No one 2. ( 1 or more people

40. What caused you excess worry, “nerves” or stress at school in the last six months? Check all the answers that apply to you.

1. ( Nothing worries or stresses me 2. ( I changed schools 3. ( Too many changes at school 4. ( Too much pressure from teachers 5. ( Weird (conflicting) schedules 6. ( I don’t have enough influence over what I do and when I do it 7. ( School work is (often) too difficult 8. ( Not enough help from teachers with school work 9. ( Too much school work 10. ( Too much responsibility 11. ( Deadlines 12. ( I don’t get enough feedback on how I’m doing 13. ( I’m bored. 14. ( I’m being sexually harassed by someone at school 15. ( I am being discriminated against 16. ( Conflict with (some) teachers 17. ( Conflict with (some) other students 18. ( I feel alone (isolated from my fellow students, lonely) 19. ( I have difficulty speaking with people at school 20. ( I am physically threatened 21. ( I’m afraid of violence 22. ( I’m afraid of weapons 23. ( Thinking about the future 24. ( I’m being pressured by friends to do what they want 25. ( I’m afraid of a teacher/teachers 26. ( I’m often hungry 27. ( I’m concerned (worried) about grades 28. ( The way classes are taught 29. ( Problems with boyfriend/girlfriend 30. ( Other (please specify): ______________________________________

41. What caused you excess worry, “nerves” or stress at home or outside school in the last six months? Check all the answers that apply to you.

1. ( Nothing worries or stresses me 2. ( A close family member or friend is ill, injured or has died 3. ( Unexpected pregnancy 4. ( Birth or expected birth of a child 5. ( My parents have unrealistic expectations of me 6. ( Pressure from home to get good marks 7. ( My parents are over-protective 8. ( I have begun a new, close relationship 9. ( A close relationship has ended 10. ( Arguments with someone close to me 11. ( Arguments with other family members (parents, stepparents, grandparents, brothers, sisters, etc.) 12. ( Abuse at home (physical, verbal or sexual) 13. ( Physical abuse from a friend 14. ( Verbal or emotional abuse from a friend 15. ( Sexual abuse from a friend/dating violence 16. ( Childcare or daycare problems 17. ( Change in living situation (moving to a new home, new roommate, family member leaving, etc.) 18. ( Being pressured to have sex 19. ( I’m afraid of getting pregnant/getting a girl pregnant. 20. ( I’m confused about my sexual identity (being heterosexual, homosexual, bisexual) 21. ( I don’t have enough money 22. ( Trouble with the law 23. ( Alcohol or drug use by a member of my family 24. ( My parents are too strict 25. ( My own alcohol or drug use 26. ( Being pressured to smoke 27. ( I have trouble balancing school and work responsibilities. 28. ( I have too much to do 29. ( I’m afraid of AIDS or other sexually transmitted diseases 30. ( I have trouble getting to and from school 31. ( I have trouble balancing home and school responsibilities 32. ( Parents split up 33. ( Parents just don’t bother about me 34. ( One of my friends started dating someone new 35. ( One or both of my parents lost their jobs 36. ( Fear of street gangs, people with weapons 37. ( Living by myself 38. ( I am worried about someone finding out I am gay/lesbian/homosexual 39. ( Family members arguing, fighting 40. ( Other (please specify): ______________________________________

42. What would you like to do to better cope/deal with worry, “nerves” or stress? Check all the answers that apply to you.

1. ( Nothing 2. ( Be more physically active 3. ( Get out more often, make new friends, socialize 4. ( Make a major change in my life (e.g. change schools, quit school, move or leave home) 5. ( Change classes 6. ( Change teachers 7. ( Drink less alcohol 8. ( Cut down on painkillers, sleeping or calming medications (prescribed) 9. ( Cut down on street/non-medical drug use 10. ( Eat better 11. ( Spend more time with my family 12. ( Reduce the amount of conflict with others at home or at school 13. ( Manage time better 14. ( Learn more about coping/dealing with worry “nerves” or stress 15. ( Learn to relax 16. ( Sleep more or sleep better 17. ( See a doctor 18 ( Earn more money 19. ( Manage money better 20. ( Quit or change my (part time) job 21. ( I don’t know what I could do 22. ( Quit smoking 23. ( Talk to someone about it 24. ( Develop my spirituality more 25. ( Other (please specify): ______________________________________

43. What is getting in the way of or stopping you from making these changes? Check all the answers that apply to you.

1. ( Nothing 2. ( Problem isn’t serious; there’s no rush 3. ( Not enough time 4. ( Not enough energy 5. ( Not enough money 6. ( Too depressed (sad) 7. ( Don’t know how to get started 8. ( No encouragement or help from family or friends 9. ( No encouragement or help from school 10. ( It’s too hard 11. ( Lack of self-confidence/unsure of myself 12. ( Don’t want to change my ways 13. ( Afraid of the future/afraid of the unknown 14. ( Not sure I can really make a difference 15. ( Don’t know where to go for help 16. ( I don’t know what is stopping me 17. ( Other (please specify): ______________________________________

44. During the last year, did you look for/seek help or counselling for a personal or emotional problem of any kind? Please check the one response that best describes you.

1. ( Yes, through my school (e.g. the guidance office, principal, teacher) or through a service provided by the school such as a “student assistance program” or “peer support program” 2. ( Yes, but not through my school 3. ( No, but I thought about it 4. ( No

Health Related Personal Health Behaviours
Physical and Social Activities

45. Some common activities are listed below. How often do you take part in each of these activities? Think about the last month as a guide and for each of the activities listed below, choose the answer from the answer key that most closely describes your participation level.

|ANSWER KEY |
|1 = seldom or never |
|2 = about once a month |
|3 = about once a week |
|4 = 2 or 3 times a week |
|5 = usually every day |

a. ___ Play or practice a league team sport, such as volleyball, hockey, ringette, soccer, bowling, or curling b. ___ Play games/do activities with friends, such as road hockey, basketball, baseball, in-line skating, skateboarding, walking, or biking c. ___ Go to organized classes, such as swimming, dance, or karate d. ___ Work out or jog for at least 15 minutes at a time e. ___ Practice a musical instrument or singing f. ___ Go to watch events, such as hockey games, baseball games, skating competitions, or gymnastic displays g. ___ Work at a hobby, such as painting, stamp collecting, model building, drawing, modelling, or acting h. ___ Go to dances i. ___ Play computer games, arcade games with friends or family j. ___ Play computer games, arcade games alone k. ___ Watch T.V. or movies; listen to radio/music with friends or family l. ___ Watch T.V. or movies; listen to radio/music alone m. ___ Hang out with family/friends, talk to friends on the phone o. ___ Surfing the internet, e-mailing and chatting online with friends

46. Some not-so-common activities are listed below. Think about the past year as a guide and for each of the activities listed below, choose the answer from the answer key that most closely describes your usual activity level.

|ANSWER KEY |
|1 = never |
|2 = once or twice |
|3 = 3 or 4 times |
|4 = 5 times or more |

How often do you take part in each of these?

a. ___ Stay out all night without permission b. ___ Skip a day of school without permission c. ___ Questioned by the police about anything you might have done, such as stealing, damaging property, or anything else d. ___ Beaten up someone who didn’t do anything to you e. ___ Taken something of value ($100.00 or more) that didn’t belong to you f. ___ Broken open a door or window and entered somewhere to steal something
47. During the school week, how often do you have breakfast, lunch or dinner? Think about the last month as a guide and for each meal listed below choose the answer from the answer key that most closely describes your usual eating pattern.

|ANSWER KEY |
|1 = hardly ever/never |
|2 = once a week |
|3 = 2 to 3 days a week |
|4 = 4 to 5 days a week |
|5 = every day |

a. ___ Breakfast (morning meal) (at least juice or toast and cereal) b. ___ Lunch (midday meal) (more than a drink or snack) c. ___ Dinner (evening meal) (more than a drink or snack)

48. If you sometimes miss or skip a meal, what is the reason? Please check all the responses that best describe you.

1. ( I never skip meals. 2. ( Not hungry/no appetite 3. ( Over slept 4. ( Not given enough time to eat 5. ( Too busy with planned activities 6. ( Want to lose weight 7. ( Forgot my lunch/money 8. ( Nothing to eat that I like 9. ( I do not have enough money 10. ( I do not like the cafeteria food 11. ( Other (please specify): ______________________________________

49. Do you think your body is: Please check one response that best describes you.

1. ( Much too thin 2. ( A bit too thin 3. ( About the right size 4. ( A bit too fat 5. ( Much too fat

50. Are you on a diet to lose weight? Please check the one response that best describes you.

1. ( No, because my weight is fine 2. ( No, but I do need to lose weight 3. ( Yes

51. Are you trying to gain weight? Please check the one response that best describes you.

1. ( No, because my weight is fine 2. ( No, but I do need to gain weight 3. ( Yes

52. About how many hours a week do you usually take part in physical activity that makes you breathe heavier (huff and puff) or feel warmer (sweat) than usual? Think about the last month as a guide and for each situation listed below, choose the answer from the answer key that most closely describes your activity pattern.

|ANSWER KEY |
|1 = none at all |
|2 = about ½ hour |
|3 = about 1 hour |
|4 = about 2 hours |
|5 = about 3 hours |
|6 = about 4 hours |
|7 = about 5 hours |
|8 = about 6 hours |
|9 = about 7 or more hours |

a. ___ In your class time in school b. ___ In your free time in school c. ___ Outside of school

53. Listed below are some common activities that students do in their out-of-school time. Think about the last month as a guide and for each situation listed below, choose the answer from the answer key that most closely describes your activity pattern.

|ANSWER KEY |
|1 = none at all |
|2 = about ½ hour |
|3 = about 1 hour |
|4 = about 2 hours |
|5 = about 3 hours |
|6 = about 4 hours |
|7 = about 5 hours |
|8 = about 6 hours |
|9 = about 7 or more hours |

How many hours a day do you usually: a. ___ Watch television, including videos b. ___ Use a computer (playing games, e-mailing, chatting, surfing the internet) c. ___ Spend time doing school homework outside of school hours d. ___ Listen to music or the radio
Smoking, Alcohol, Medication and Other Drugs

We would like to remind you that this questionnaire is completely confidential. No one from your school will be able to identify you. All the questionnaires will be placed together so no individual questionnaire can be identified.

54. Have you ever smoked tobacco? Please check the one response that best describes you.

1. ( No, never 2. ( Yes, I have tried a few puffs 3. ( Yes, occasionally (less than once a week) 4. ( Yes, regularly (at least once a week)

55. How often do you smoke? Please check the one response that best describes you.

1. ( I do not smoke 2. ( Less than once a week 3. ( At least once a week but not every day 4. ( Every day

56. How many cigarettes do you usually smoke a day? Please check the one response that best describes you.

1. ( I do not smoke 2. ( Fewer than 10 3. ( 10 or more

57. How often do you drink anything alcoholic such as beer, wine or liquor? Include even those times when you only drink a small amount. Using the answer key below, place the number of your answer beside each type of alcohol.

|ANSWER KEY |
|1 = never |
|2 = less than once a month |
|3 = every month |
|4 = every week |
|5 = every day |

a. ___ Beer b. ___ Wine c. ___ Liquor d. ___ Coolers

58. Have you ever had so much alcohol that you were actually drunk? Please check the one response that best describes you.

1. ( I do not drink alcohol 2. ( No, never 3. ( Yes, once 4. ( Yes, 2-3 times 5. ( Yes, 4-10 times 6. ( Yes, more than 10 times

59. On a typical drinking occasion, about how much alcohol do you usually consume? Please check the one response that best describes you.

1. ( I do not drink alcohol 2. ( 1 or 2 drinks 3. ( 3 or 4 drinks 4. ( 5 or 6 drinks 5. ( 7 or more drinks

60. On a typical drinking occasion, do you drink until you get drunk? Please check the one response that best describes you.

1. ( I do not drink alcohol 2. ( Never 3. ( Rarely 4. ( Sometimes 5. ( Often

61. Using the answer key below, place the number of your answer beside each ailment.

|ANSWER KEY |
|1 = no |
|2 = yes, once |
|3 = yes, more than once |

During the last month have you taken any medicine or pills for each of the following reasons?

a. ___ A cough b. ___ A cold c. ___ Headache d. ___ Stomach-ache e. ___ Difficulty sleeping f. ___ Nervousness
62. Using the answer key, place the number of the answer that best describes your behaviour beside each drug.

|ANSWER KEY |
|1 = never |
|2 = once or twice |
|3 = three times or more |

How often have you taken any of the following drugs?

a. ___ Hashish/marijuana (e.g. hash, grass) b. ___ Solvents (e.g. glue sniffing) c. ___ Cocaine (e.g. crack) d. ___ Heroin/opium/morphine e. ___ Amphetamines (e.g. uppers, speed) f. ___ LSD (e.g. acid) g. ___ Medical drugs to get stoned (e.g. tranquillizers such as Valium, or sedatives such as Seconal) h. ___ E or ecstasy i. ___ Steroids
Health and Safety

The following questions deal with things people do that protect their health and safety.
We would like to remind you that this questionnaire is completely confidential. No one from your school will be able to identify you. All the questionnaires will be placed together so no individual questionnaire can be identified.

63. Have you ever had sexual intercourse? Please check the one response that best describes you.

1. ( No 2. ( Yes

64. The last time you had sexual intercourse, did you or your partner use a condom? Please check the one response that best describes you.

1. ( I have never had sexual intercourse 2. ( No 3. ( Yes

65. The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy? Please check the one response that best describes you.

1. ( I have never had sexual intercourse 2. ( No method was used to prevent pregnancy 3. ( Birth control pills 4. ( Condoms 5. ( Spermicidal spray or foam 6. ( Withdrawal 7. ( Morning after pill 8. ( Some other method 9. ( Not sure

66. Before your last intercourse, did you drink alcohol and/or use drugs? Please check the one response that best describes you.

1. ( I have never had sexual intercourse 2. ( No 3. ( Yes

67. How often do you use a seatbelt when you ride in a car? Please check the one response that best describes you.

1. ( I never travel by car 2. ( Seldom or never 3. ( Sometimes 4. ( Often 5. ( Always 6. ( Usually there is no seat belt where I sit

68. Using the answer key, please choose the response that best describes your behaviour for each of the following activities.

|ANSWER KEY |
|1 = I do not do this activity |
|2 = seldom or never |
|3 = sometimes |
|4 = often |
|5 = always |

How often do you wear a helmet and other protective gear when you participate in or do the following activities?

a. ___ Ride a bicycle b. ___ In-line skate (roller-blade) c. ___ Skateboard or ride a scooter d. ___ Downhill skiing or snowboarding e. ___ Participate in non-league or pick-up sports f. ___ Drive or ride an ATV g. ___ Drive or ride a snowmobile h. ___ Drive or ride a motorbike

69. Would you ride as a passenger in a car with a friend who had been drinking? Please check the one response that best describes you.

1. ( Definitely not 2. ( Maybe (depends on how much he/she drank) 3. ( Probably 4. ( I don’t know

70. What would you do if a friend, whose opinion you valued, dared you to do something dangerous or something that could get you in trouble? Please check the one response that best describes you.

1. ( I would do it without hesitation 2. ( I am not sure (it would depend on who the friend was or the exact situation) 3. ( I would probably refuse, or get out of it somehow 4. ( I would definitely refuse
Spiritual Life

71. How important is it for you to have a spiritual part to your life (however you choose to define “spiritual”)? Please check the one response that best describes you.

1. ( Very important 2. ( Fairly important 3. ( Not important

72. How often do you go to a place of worship (e.g. church, temple, mosque)? Please record your usual practice. Check all responses that apply.

1. ( I do not go to a place of worship 2. ( Rarely (no particular pattern) 3. ( On special occasions (e.g. weddings, christening) 4. ( On special days in the religious year (e.g., Hanukkah, Christmas, Easter, Eid) 5. ( Regularly during certain seasons (e.g., Lent, Advent, Ramadan) 6. ( Once a month 7. ( Two or three times a month 8. ( Every week, or almost every week (this may mean Saturdays or Sundays and/or other weekday services)

73. Which of the following reasons for going to a place of worship apply to you? Please check all that apply.

1. ( I do not go to a place of worship 2. ( I go when I want to 3. ( I go when someone puts pressure on me to go 4. ( I go when I feel I ought to go 5. ( Other (please specify): ______________________________________

74. Please indicate which of the following statements best describes your practice with regard to prayer. Please check the one response that best describes you.

1. ( I pray every day, or nearly every day 2. ( I pray occasionally 3. ( I do not pray at all

How Your School Can Help

75. How do you think your school can help you improve or maintain your health? Please check all the items that would be helpful to you personally.

1. ( Obtain more input or advice from students on how the school is run 2. ( Train teachers to be more sensitive to students’ concerns 3. ( Communicate more openly with students 4. ( Provide assistance programs to help students get personal counselling on personal, financial or other problems 5. ( Provide peer helper groups 6. ( Provide support groups for students with special needs 7. ( Provide conflict resolution/mediation programs 8. ( Deal with violence/weapons 9. ( Treat students with greater respect 10. ( Deal with racism 11. ( Support or provide daycare 12. ( Offer family support groups 13. ( Provide counselling about STD’s, HIV/AIDS, pregnancy, sexual abuse, making choices, etc. 14. ( Provide more team support opportunities 15. ( Provide or support healthy eating/weight-control groups 16. ( Make physical activity/sport facilities more available and accessible (e.g. before school, after school, weekends) 17. ( Provide or support stop-smoking programs 18. ( Help reduce causes of student stress 19. ( Help integrate persons with disabilities into school activities 20. ( Increase physical activity opportunities in class time 21. ( Encourage students to spend time improving their health 22. ( Provide better food in the cafeteria 23. ( Provide workshops, courses or advice/counselling on making personal choices/decisions 24. ( Provide workshops or courses on anger control 25. ( Provide workshops or courses on assertiveness 26. ( Provide workshops or courses on time management 27. ( Provide workshops or courses on money management 28. ( Provide workshops or courses on stress management 29. ( Provide workshops or courses on parenting 30. ( Provide workshops or courses on relationship negotiation skills 31 ( Provide workshops or courses on communication skills 32. ( Change the type of physical activity offered in physical education classes 33. ( Ensure teachers are better prepared for their classes 34. ( Offer more fun school activities (e.g. winter carnival, wall climbing, spirit days) 35. ( Deal with bullying in the school 36. ( Improve accessibility for students with disabilities 37. ( There is nothing the school can do 38. ( Other (please specify): ______________________________________
76. Of all the items you checked in question 75, what do you consider to be the top 3 priorities that your school should do to help you improve or maintain your health? Please write the number in the space below of each of your top 3 choices that appear in question 75.

My first priority is: item # ___ My second priority is: item # ___ My third priority is: item # ___

This page is designed for you to tear off and take with you.

If you have a worry or concern that you would like some help with, visit your school’s Student Services office and/or call the following number for assistance:

Kids Help Phone (no charge): 1-800-668-6868 www.kidshelpphone.ca Thanks for taking the time to complete this questionnaire.
You have played an important role in helping your school to become a safer, healthier and more caring place.