An Impact Evaluation of Training in Multi-Tiered Systems of mSupport for Behavior (MTSS-B)

Student
Survey

Multi-Tiered Systems of Support for Behavior

(MTSS-B)

Student Name:

___________________________________

(Label provided by survey firm)

Student ID:

___________________________________

(Label provided by Survey Firm)

We would like to ask you some questions about yourself and your school. We are going to read all questions aloud to you. Please follow along in your booklet. You do not have to answer any question you do not want to answer. Your participation in this survey is completely voluntary, but your answers will be very helpful for improving your school. Your answers will be kept private and the surveys will be kept in a safe place; only researchers working on this project will see them. Teachers, parents, and others in your community will not have access to your responses to the questions. Your parents have also agreed that it is okay for you to answer these questions. If you have any questions, you can ask them now, or afterwards. We will give you the phone number of someone at MDRC that you can call.

If you agree to answer some questions about yourself and your school, please sign your name here:

____________________________________________________________: Student Signature

Please do not write your name inside this form or the answer sheet. Do not identify yourself in any other way. Write clearly and fill in circles with a pencil or blue/black ink pen. Mark only one answer for each question.

Once you have answered all of the questions, please close the booklet and wait for the person assisting with this study to collect it from you. If you have any questions during the survey, please raise your hand.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is #1850-NEW. The time to complete this survey is estimated to average 20 minutes, including time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. The obligation to respond to this collection is voluntary. If you have comments or concerns regarding the status of your individual submission of this form, application or survey, please write directly to Lauren Angelo, U.S. Department of Education, Institute of Education Sciences, 555 New Jersey Avenue, NW, Suite 502h, Washington, D.C. 20208 or email [email protected].

Thank you for taking time to answer these questions!

A1.	Are you a boy or girl?
	1	Boy
	2	Girl

A2.	What grade are you in?
	1	Grade 4
	2	Grade 5
	3	Other

A3.	How old are you?
	1	6
	2	7
	3	8
	4	9
	5	10
	6	11
	7	12
	8	13
	9	Other

B1.	How much do you agree or disagree with each of these statements?
	I feel safe…	Strongly Agree	Agree	Disagree	Strongly Disagree
	At this school	1	2	3	4
	Going to and from this school	1	2	3	4

B2.	Based on your experience, how much of a problem at this school is physical fighting between students?
	Large Problem	Somewhat a Problem	Small Problem	Not a Problem
	1	2	3	4

B3.	Based on your experience, how much of a problem at this school is bullying of students?
	Bullying is when a student is treated badly by another student or a group of students. This behavior is repeated again and again, over time. Kids who bully use their power such as physical strength, access to embarrassing information, or popularity to control or harm others. Bullying includes actions like threatening, teasing, name-calling, ignoring, rumor spreading, sending hurtful emails and text messages, and leaving someone out on purpose.
	Large Problem	Somewhat a Problem	Small Problem	Not a Problem
	1	2	3	4

C1.	How much do you agree or disagree with each of these statements?
		Strongly Agree	Agree	Disagree	Strongly Disagree
	My teachers tell me when I do a good job	1	2	3	4
	I like coming to school	1	2	3	4
	I like this school	1	2	3	4

D1.	How much do you agree or disagree with each of these statements?
		Strongly Agree	Agree	Disagree	Strongly Disagree
	I believe I can do well at this school	1	2	3	4
	My teachers encourage me to work hard in my classes	1	2	3	4
	It is important to finish high school	1	2	3	4

E1.	How much do you agree or disagree with each of these statements?
		Strongly Agree	Agree	Disagree	Strongly Disagree
	It is okay to hit someone if they hit me first	1	2	3	4
	If people do something that makes me really mad, they deserve to be beaten up	1	2	3	4
	I believe it is okay to hurt people who hurt me first	1	2	3	4

E2.	How often do you feel this way?
		Almost always	Often	Sometimes	Never
	I am sad	1	2	3	4
	I get mad easily	1	2	3	4
	I am lonely	1	2	3	4
	I feel nervous	1	2	3	4

F1.	How much do you agree or disagree with each of these statements?
	At this school	Strongly Agree	Agree	Disagree	Strongly Disagree
	I feel like I belong	1	2	3	4
	Students help one another	1	2	3	4
	My teachers listen to me when I have something to say	1	2	3	4
	My teachers care about me	1	2	3	4

G1.	How much do you agree or disagree with each of these statements?
	At this school…	Strongly Agree	Agree	Disagree	Strongly Disagree
	Students disobey the rules	1	2	3	4
	Students listen to the teachers	1	2	3	4
	Students get along well with each other	1	2	3	4
	Students are rewarded for positive behavior	1	2	3	4
	Everyone knows what the school rules are	1	2	3	4
	The school rules are strictly enforced	1	2	3	4
	If a rule is broken, students know the consequences	1	2	3	4
	Punishments are the same no matter who you are	1	2	3	4

H1.	How much do you agree or disagree with each of these statements?
	At this school….	Strongly Agree	Agree	Disagree	Strongly Disagree
	Students of all races are treated the same	1	2	3	4
	All students are treated equally, regardless of whether their parents are rich or poor	1	2	3	4
	Boys and girls are treated the same	1	2	3	4

I1.	The following questions ask about bullying. Bullying is when a student is treated badly by another student or a group of students. This behavior is repeated again and again, over time. Kids who bully use their power such as physical strength, access to embarrassing information, or popularity to control or harm others. Bullying includes actions like threatening, teasing, name-calling, ignoring, rumor spreading, sending hurtful emails and text messages, and leaving someone out on purpose.
	At this school…	Several times a week	Once a week	2-3 times a month	1 time during the month	Not at all
	During the past 30 days, how often have you been bullied?	1	2	3	4	5
	In the past 30 days, how often have you bullied someone else?	1	2	3	4	5

Thank you for taking the time to complete this survey. Your opinion is very important to us. The information that you provided will be used to improve your school's climate.

There is always an adult at your school who you can talk to about your feelings and the school climate. If you have any questions about the survey, or want to talk with someone about any concerns you might have, please see a counselor or a school psychologist.