Thank you for agreeing to participate in this survey. The purpose of this survey is to learn how students health behaviors impact their academic performance. The survey is completely voluntary and anonymous. DO NOT put your name on the questionnaire.
This is not a test, so there are no right or wrong answers. We would like you to work quickly so you can finish. All of the questions should be answered by completely filling in one of the answer spaces. If you do not find an answer that fits exactly, use the one that comes closest. If any question does not apply to you, or you are not sure what it means, just leave it blank. You can skip any question that you do not wish to answer.
Are you ? MALE__ OR FEMALE__
Are you Hispanic or Latino? Yes No
What is your race? (Mark all that apply.)
American Indian or Alaska Native
Asian Black or African American
Hawaiian or
Other Pacific Islander
White
Next section asks about your experiences at school.
In my school, students have lots of chances to help decide things like class activities and rules.
Disagree Strongly agree Strongly disagree Agree
I have lots of chances to be part of class discussions or activities.
Disagree Strongly agree Strongly disagree Agree
6. During the past 30 days, how many days of school have you missed because you skipped or ‘cut’?
4-5 days
6-10 days
11 or more days
1 day
2 days
3 days
7. Putting them all together, what were your grades like last semester?
Mostly P’s
Mostly F’s
Now thinking back over the past year in school, how often did you:
8.enjoy being in school?
Seldom Often Never Sometimes Almost always
9. try to do your best work?
Seldom Often Never Sometimes Almost always
10. Feel that the school work you were assigned was meaningful and important?
Seldom Often Never Sometimes Almost always
11. How do you feel about your education?
A. Waste of my time
B. Only important to get a job
C. To advance my knowlegde
D. Forced to go by govt. or parent
12.Have you ever smoked weed before?
A. Yes
B. No
13.How often do you smoke weed?
A. Never
B. Once a month
C. Once a week
D. Once a day
E. As often as I can
14.What are your views on marijuana legalization?
A. It should happen
B. No opinion
C. Only for medical use
D. Stay illegal
15. Do your parents know you smoke marijuana?
A. Yes
B. No
C. They supply it
Open-ended write in 1 or 2 sentences:
16. Why did you start smoking weed?
17. Would you stop smoking if you failed a class?
Adapted by
Arizona School Survey
Phoenix, AZ 85007 (602) 364-1146
http://www.azcjc.gov/acjc.web/sac/ays.aspx
