These are some questions about things you might do in your every day life.  Think about the last month or so. 
How much would you agree that this is like you?

 

	Strongly Disagree	<<<	..........	>>>	Strongly Agree
12. I calm myself down when I get excited or wound up.	1	2	3	4	5
13. I recognize how other people might be feeling.	1	2	3	4	5
14. I interrupt when other people are talking.	1	2	3	4	5
15. I communicate my thoughts and feelings clearly.	1	2	3	4	5
16. I settle an argument without fighting or yelling.	1	2	3	4	5
17. I have trouble waiting in line patiently.	1	2	3	4	5
18. I respect others despite differences (like race, beliefs or abilities).	1	2	3	4	5
19. I think before I speak.	1	2	3	4	5
20. I help out in my community.	1	2	3	4	5
21. I choose friends who avoid trouble.	1	2	3	4	5
22. I have an important role model in my life.	1	2	3	4	5

Choose how many times you did these behaviors in the LAST 30 DAYS.

1. In the last 30 days... How many time did you encourage other people to fight...

 

	Never	1 time	2 times	3 times	4 times	5 or more times
1a. at home or in the neighborhood?	0	1	2	3	4	5
1b. at school?	0	1	2	3	4	5

2. In the last 30 days... How many times did you push, shove, slap, or kick another person...

 

	Never	1 time	2 times	3 times	4 times	5 or more times
2a. at home or in the neighborhood?	0	1	2	3	4	5
2b. at school?	0	1	2	3	4	5

3. In the last 30 days... How many times did you hurt someone on purpose...

 

	Never	1 time	2 times	3 times	4 times	5 or more times
3a. at home or in the neighborhood?	0	1	2	3	4	5
3b. at school?	0	1	2	3	4	5

Choose how many times you did these behaviors in the LAST 30 DAYS.

4. In the last 30 days... How many times did you threaten to hit or hurt another person...

The next questions ask about how you see yourself in the near future.  We all think about the future at times. 
Sometimes we imagine what we would like to be, or aspire to, for example many students aspire to go to
a good high school.  Other times, we worry about how we will be, like thinking we might have a problem staying
organized in middle school. 
These are often different from how we think we will really be.

Think about how you would like to be or what you hope to do this school year.  How much do you agree you aspire to
these different things in this school year?

Think about the 5 closest friends you spend time with. These can be friends from anywhere like your school or neighborhood.

 

How many of your 5 friends do these things...	Zero	One	Two	Three	Four	Five
1. Smoke cigarettes?	0	1	2	3	4	5
2. Drink alcohol (beer, wine, liquor)?	0	1	2	3	4	5
3. Talk or act disrespectfully to teachers?	0	1	2	3	4	5
4. Get into physical fights with other kids?	0	1	2	3	4	5
5. Tell his/her friends to stop liking or being friends with someone?	0	1	2	3	4	5
6. Pay attention in school?	0	1	2	3	4	5
7. Work hard in school?	0	1	2	3	4	5
8. Stay out of trouble?	0	1	2	3	4	5
9. Participate in activities that have an adult in charge (like sports teams, dance, music lessons or groups, community service, church groups)?	0	1	2	3	4	5
10. Do volunteer work?	0	1	2	3	4	5

How much do you agree or disagree with the following statements about your parents or guardians?

 

I have a parent/guardian who...	Strongly Disagree	<<<	........	>>>	Strongly     Agree
1. Makes me feel better after talking over my worries with him or her.	1	2	3	4	5
2. Has rules that I must follow.	1	2	3	4	5
3. Really knows who my friends are.	1	2	3	4	5
4. Is always trying to change how I feel or think about things.	1	2	3	4	5
5. Tells me what time I must come home.	1	2	3	4	5
6. Makes rules without asking what I think.	1	2	3	4	5
7. Smiles at me very often.	1	2	3	4	5
8. Makes sure I say where I am going.	1	2	3	4	5
9. Really knows where I go at night.	1	2	3	4	5
10. Makes sure I go to bed on time.	1	2	3	4	5
11. Is able to make me feel better when I am upset.	1	2	3	4	5

How much do you agree or disagree with the following statements about your parents or guardians?

I have a parent/guardian who...	Strongly Disagree	<<<	........	>>>	Strongly     Agree
12. Asks me what I do with friends.	1	2	3	4	5
13. Really knows how I spend my money.	1	2	3	4	5
14. Really knows where I am after school.	1	2	3	4	5
15. Changes the subject whenever I have something to say.	1	2	3	4	5
16. Checks to see if I do my homework.	1	2	3	4	5
17. Really knows what my grades are.	1	2	3	4	5
18. Really knows when I have misbehaved at school.	1	2	3	4	5
19. Enjoys doing things with me.	1	2	3	4	5
20. Really knows what classes I am taking.	1	2	3	4	5
21. Really knows what I do with my free time.	1	2	3	4	5
22. Often interrupts me.	1	2	3	4	5
23. Cheers me up when I am sad.	1	2	3	4	5
24. Blames me for other family members.	1	2	3	4	5

How much do you agree or disagree with the following statements about your parents or guardians?

 

I have a parent/guardian who...	Strongly Disagree	<<<	........	>>>	Strongly     Agree
25. Gives me lots of care and attention.	1	2	3	4	5
26. Brings up past mistakes when she or he criticizes me.	1	2	3	4	5
27. Makes me feel like the most important person in his or her life.	1	2	3	4	5
28. Will avoid looking at me when I have disappointed her or him.	1	2	3	4	5
29. Believes in showing her or his love for me.	1	2	3	4	5
30. Is less friendly with me if I do not see things his or her way.	1	2	3	4	5
31. Often praises me.	1	2	3	4	5
32. If I have hurt his or her feelings, stops talking to me until I please her or him again.	1	2	3	4	5
33. Is easy to talk to.	1	2	3	4	5

Lots of kids say or do things to hurt other people sometimes.
These questions are about how often you do these things in different situations.

 

	Never	<<<	<<<	......	......	......	......	>>>	>>>	Almost Always
1. When I'm hurt by someone, I fight back.	1	2	3	4	5	6	7	8	9	10
2. I threaten others to get what I want.	1	2	3	4	5	6	7	8	9	10
3. If others upset or hurt me, I tell my friends to stop liking them.	1	2	3	4	5	6	7	8	9	10
4. I tell my friends to stop liking someone to get what I want.	1	2	3	4	5	6	7	8	9	10
5. When I'm threatened by someone, I threaten back.	1	2	3	4	5	6	7	8	9	10
6. I hit, kick, or punch others to get what I want.	1	2	3	4	5	6	7	8	9	10
7. If others have hurt me, I keep them from being in my group of friends.	1	2	3	4	5	6	7	8	9	10
8. I keep others from being in my group of friends to get what I want.	1	2	3	4	5	6	7	8	9	10
9. If others have angered me, I hit, kick, or push them.	1	2	3	4	5	6	7	8	9	10

Lots of kids say or do things to hurt other people sometimes.
These questions are about how often you do these things in different situations.

 

	Never	<<<	<<<	......	......	......	......	>>>	>>>	Almost Always
10. To get what I want, I put others down.	1	2	3	4	5	6	7	8	9	10
11. When I am upset with others, I ignore or stop talking to them.	1	2	3	4	5	6	7	8	9	10
12. To get what I want, I ignore or stop talking to others.	1	2	3	4	5	6	7	8	9	10
13.  If others make me mad or upset, I hurt them.	1	2	3	4	5	6	7	8	9	10
14. To get what I want, I say mean things to others.	1	2	3	4	5	6	7	8	9	10
15. When I am mad at others, I gossip or spread rumors about them.	1	2	3	4	5	6	7	8	9	10
16. To get what I want, I gossip or spread rumors about others.	1	2	3	4	5	6	7	8	9	10
17. To get what I want, I hurt others.	1	2	3	4	5	6	7	8	9	10

The next questions are about school. Please mark how often you do the following,
where 1 is NEVER and 5 is VERY OFTEN.

 

How Often...	Never	<<<	........	>>>	Very Often
1. Do you take part in class discussions or activities?	1	2	3	4	5
2. Do you think your schoolwork is boring?	1	2	3	4	5
3. Do you put a lot of energy into what you want to do in school?	1	2	3	4	5
4. Do you think the things you learn in school are worthless?	1	2	3	4	5
5. Do you "doodle" or pass notes at school?	1	2	3	4	5
6. Do you think your homework is fun to do?	1	2	3	4	5
7. Do you present something that you've worked on to the class?	1	2	3	4	5
8. Do you daydream in school?	1	2	3	4	5
9. Do you just get by in school, rather than trying to do your best you can?	1	2	3	4	5
10. Do you feel you want to know even more about something you learned in school?	1	2	3	4	5

The next questions are about school. Please mark how often you do the following,
where 1 is NEVER and 5 is VERY OFTEN.

 

How Often...	Never	<<<	........	>>>	Very Often
11. Do you put your best effort into doing your homework?	1	2	3	4	5
12. Do you only feel half awake during school?	1	2	3	4	5
13. Do you find yourself "clock watching" in school?	1	2	3	4	5
14. Are you interested in the work your teachers give you?	1	2	3	4	5
15. Do you think the facts you learn in school are of no value?	1	2	3	4	5
16. Do you really pay attention to what the teacher is saying?	1	2	3	4	5
17. Do you think you're assigned homework just to keep you busy?	1	2	3	4	5
18. Do you do extra work on your own for your classes?	1	2	3	4	5
19. Do you really enjoy this school?	1	2	3	4	5
20. Do you rush through your homework just to get it done?	1	2	3	4	5

Now think about how many DAYS (0-30) you have done each of these things in the LAST 30 DAYS.
Write the number of days in the blank

 

	Number of Days
How many days in the LAST 30 DAYS did you...	(0-30)
1. Drink alcoholic beverages (beer, wine, liquor) not including for religious purposes?	1
2. Carry a gun?	2
3. Carry a weapon other than a gun or knife?	3
4. Get into a physical fight (slapping, hitting or shoving) in which you tried to hurt someone but did not?	4
5. Help another student with schoolwork?	5
6. Get into a physical fight in which you knocked someone down or hurt him or her?	6
7. Hang around with kids who get in trouble a lot?	7
8. Steal something from a person worth more than $50?	8
9. Sell drugs or help others sell or deliver drugs.	9
10. Steal something from a store worth more than $50?	10
11. Smoke a cigarette, even a puff?	11
12. Use marijuana (sometimes called grass, weed, or pot)?	12
13. Carry a knife?	13
14. Take a day off from school when you should have been there (hooking)?	14

Think about the Math, Language Arts and Social Studies classes you are taking this year.
How much do you agree or disagree with the following statements, where 1 is Strongly
Disagree and 5 is Strongly Agree?

 

Math	Strongly Disagree	<<<	..........	>>>	Strongly Agree
1. MATH will be useful to me in the future.	1	2	3	4	5
2. I usually pay attention.	1	2	3	4	5
3. I try to do my best.	1	2	3	4	5
4. I keep up with my work.	1	2	3	4	5

 

Language Arts	Strongly Disagree	<<<	..........	>>>	Strongly Agree
5. LANGUAGE ARTS will be useful to me in the future.	1	2	3	4	5
6. I usually pay attention.	1	2	3	4	5
7. I try to do my best.	1	2	3	4	5
8. I keep up with my work.	1	2	3	4	5

 

Social Studies	Strongly Disagree	<<<	..........	>>>	Strongly Agree
9. SOCIAL STUDIES will be useful to me in the future.	1	2	3	4	5
10. I usually pay attention.	1	2	3	4	5
11. I try to do my best.	1	2	3	4	5
12. I keep up with my work..	1	2	3	4	5

What grade did you get on your last report card for the last quarter in the following subjects?

We want to know about how your parents think you should get along with other kids. 
How much do you agree with these comments about what your parent or guardian would want you to do in tough situations?

 

My parent/guardian wants me to...	Strongly Disagree	<<<	<<<	......	......	......	......	>>>	>>>	Strongly     Agree
1. Ignore someone if he or she calls me a name.	1	2	3	4	5	6	7	8	9	10
2. Tell a teacher or another adult if someone asks me to fight.	1	2	3	4	5	6	7	8	9	10
3. Try to talk my way out of it if someone asks me to fight.	1	2	3	4	5	6	7	8	9	10
4. Think a problem through, calm myself, and then talk the problem out with my friend.	1	2	3	4	5	6	7	8	9	10
5. Hit someone back if he or she hits me.	1	2	3	4	5	6	7	8	9	10
6. Hit someone if he or she calls me names.	1	2	3	4	5	6	7	8	9	10
7. Call someone names back if he or she calls me names first.	1	2	3	4	5	6	7	8	9	10
8. Take the first swing if someone asks me to fight.	1	2	3	4	5	6	7	8	9	10
9. Solve problems by fighting if they can't be solved by talking.	1	2	3	4	5	6	7	8	9	10
10. Stay and fight instead of walking away so I won't be a coward or a "chicken".	1	2	3	4	5	6	7	8	9	10
11. Stay and fight so I won't get "picked on" even more.	1	2	3	4	5	6	7	8	9	10
12. Find other ways to solve my problems because fighting is no good.	1	2	3	4	5	6	7	8	9	10

These are some questions about how you feel about what kinds of things other kids might do.  Do you think it is OK for kids your age to do the following?

 

It is okay for kids my age to...	Strongly Disagree	<<<	<<<	......	......	......	......	>>>	>>>	Strongly     Agree
1. Smoke cigarettes.	1	2	3	4	5	6	7	8	9	10
2. Drink alcohol.	1	2	3	4	5	6	7	8	9	10
3. Use illegal drugs.	1	2	3	4	5	6	7	8	9	10
4. Cheat on a school test.	1	2	3	4	5	6	7	8	9	10
5. Bully/pick on other kids.	1	2	3	4	5	6	7	8	9	10
6. Disrupt class.	1	2	3	4	5	6	7	8	9	10
7. Go places that are dangerous or off-limits.	1	2	3	4	5	6	7	8	9	10
8. Spread rumors or gossip about others to hurt them.	1	2	3	4	5	6	7	8	9	10
9. Ignore or stop talking to friends to hurt them.	1	2	3	4	5	6	7	8	9	10
10. Tell their friends to stop liking or being friends with someone.	1	2	3	4	5	6	7	8	9	10
11. Keep others from being in your group.	1	2	3	4	5	6	7	8	9	10
12. Get into physical fights.	1	2	3	4	5	6	7	8	9	10

Think about how you have been feeling over the last 30 days.  Mark the number that goes with
how often you have felt or done each of these.

 

How Often...(over the last 30 days)	Never	Seldom	Sometimes	Often	Always
1. Were you very sad?	1	2	3	4	5
2. Were you grouchy or irritable, or in a bad mood?	1	2	3	4	5
3. Did you feel hopeless about the future?	1	2	3	4	5
4. Did you feel like not eating or eating more than usual?	1	2	3	4	5
5. Did you sleep a lot more or a lot less than usual?	1	2	3	4	5
6. Did you have difficulty concentrating on your school work?	1	2	3	4	5

The next questions ask about adults in your life other than your parents or guardians.  You might know these adults from school, your church or in your community.  How much do you agree or disagree with the following statement?

 

I have an adult in my life...	Strongly Disagree	<<<	<<<	......	......	......	......	>>>	>>>	Strongly     Agree
1. With whom I can talk about personal problems.	1	2	3	4	5	6	7	8	9	10
2. Who is concerned with my well being.	1	2	3	4	5	6	7	8	9	10
3. Who is there for me if I need help.	1	2	3	4	5	6	7	8	9	10
4. Who encourages me often.	1	2	3	4	5	6	7	8	9	10
5. Who is a good role model.	1	2	3	4	5	6	7	8	9	10
6. Who has made a positive difference in my life.	1	2	3	4	5	6	7	8	9	10

On most WEEKDAYS (Monday - Friday) and WEEKEND DAYS (Saturday or Sunday)
how much time do you spend watching or playing...

 

		Less than 5 minutes	5 minutes - less than 30 minutes	30 minutes - less than 1 hour	1 hours - less than 3 hours	3 hours - less than 5 hours	5 hours or more
1. TV	a. Weekday	1	2	3	4	5	6
	b. Weekend day	1	2	3	4	5	6
2. MOVIES (videos, DVDs, movie theatre)	a. Weekday	1	2	3	4	5	6
	b. Weekend day	1	2	3	4	5	6
3. VIDEO GAMES	a. Weekday	1	2	3	4	5	6
	b. Weekend day	1	2	3	4	5	6

Adapted from Rideout, Roberts, and Foehr (2005).

 Think about the TV, MOVIES, and VIDEO GAMES you watch.

On most WEEKDAYS (Monday - Friday) and WEEKEND DAYS (Saturday or Sunday)
how much time do you spend watching or playing programs where someone is ...

Adapted from children's Report of Exposure to Violence (CREV) scale by Cooley et. al. (1995).