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  1. 1. Purpose of the SurveyThis survey provides an opportunity to share your thoughts on what you feel is needed to ensurethat you and your school can be as safe, healthy and supportive as possible.You do not have to fill out ALL QUESTIONS in this survey if you do not want to. However, everyone’sviews are important. Please understand that this questionnaire is completely confidential.Name: João Gabriel Rocha Couto GomesGroup: 1° FYour BackgroundIn your opinion, what kind of grades (marks) do you usually get in English?Please check the one response that best describes you.A) Not very good B) Fair C) Average D) Very good X) ExcellentWhat do you think you will be doing when you finish high school at Dom Silvério?Please check the one response that best describes you.A) LawB) MedicineC) EngineerD) ArchitectE) EconomistF) PsychologistG) Web DeveloperH) UncertainX) Other: _Programmer____________________________________People live in different types of families. Sometimes people live with just one parent, sometimes theylive with each parent but in different homes, or sometimes they live in different situations.If you live in only one home, or where you live most of the time, please check all the people you livewith.( X ) Mother ( X ) Father ( ) Stepmother ( ) Stepfather ( ) Foster family or group home( X ) Brothers (include step, half and foster brothers)Sisters (include step, half and foster sisters)( ) Grandmother ( ) Grandfather ( ) Other relatives ( ) Other people( ) I live on my ownAre you responsible for anyone at home on either a part time or full time basis (e.g. a sick or elderlyrelative, parent, a younger brother or sister, child)? ( )Yes ( X ) NoHow long have you lived in Belo Horizonte?( X ) Since birth ( ) More than 5 years ( ) 1-2 years ( ) Less than one yearYour HealthIn your opinion, how would you describe your health? Please check the one response that bestdescribes you.( ) Poor ( ) Fair ( ) Good ( X ) Very good ( ) ExcellentDo 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.( X )Yes ( ) No
  2. 2. If you have a disability, long-term illness or chronic condition, please check the relevant categorybelow. Please check all responses that apply to you.( ) I do not have such a condition.( ) Learning disability( ) Physical disability( ) Emotional disability( ) Allergies (food)( ) Allergies (respiratory)( X ) Asthma( ) Diabetes( ) Other (please specify): ______________________________________Does your disability, long-term illness or chronic condition affect your attendance and participationat school? Please check the one response that best describes you.I do not have such a condition( )Yes ( X ) NoWhat would you like to do in the next year to improve or maintain your health?Please check all the responses that apply to you.( ) Drink less coffee or tea( X ) Eat healthier foods( ) Be more physically active( ) Remove a major source of worry, nerves or stress from my life( ) Learn to cope better with worry, nerves or stress( ) Spend less hours on Internet( ) Quit smoking or smoke less( ) Be less dependent of Mobile phones( ) Cut down on painkillers, sleeping or calming medications( ) Lose weight( ) Gain weight( ) Skip fewer meals( ) Learn to be more assertive( ) Learn to control anger (better)( ) Learn to communicate (better)( ) Learn to deal with relationships( ) Learn to manage time (better)( ) Learn to manage money (better)( ) Deal/cope with an eating disorder( ) Deal/cope with bullying( ) Deal/cope with violence( ) Nothing( ) Other (please specify): ______________________________________What is stopping you from making this change? Please check all the responses that apply to you.( ) Nothing( ) Problem isn’t serious, there’s no rush( ) My boyfriend/girlfriend is not supportive( ) Difficult situation at home( ) Not enough time( ) Not enough energy( ) Not enough money( ) I’m too depressed (sad)( X ) I don’t know how to get started
  3. 3. ( ) No encouragement or help from family and friends( ) No encouragement or help from school( ) It is too hard( ) I don’t want to change my ways( ) I’m not sure I really can make a difference( ) I have too much stress right now( ) I’m afraid of the unknown (future)( ) I’m unsure of myself (lack self-confidence)( ) I don’t know what is stopping me( ) It is not important to me( ) I don’t feel like it( ) Other (please specify): ______________________________________How many hours do you usually sleep at night?Please check the one response that best describes you.( ) 0 to 4 hours ( ) 5 to 6 hours ( X ) 7 to 8 hours ( ) 9 hours or moreYour FeelingsFor 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 KEY1 = strongly disagree2 = disagree3 = not sure4 = agree5 = strongly agreea._4__I have trouble making decisionsb._5__I have confidence in myself (I am sure of myself)c._3__I would change how I look, if I couldd._3__I have usually found that what is going to happen will happen, regardless of my planse._3__I usually behave according to my beliefsf.__4_My life is full of meaning and purposeg._5__On the whole, it seems to me that things turn out the way they shouldh._4__I like myselfi.__3_My parents understand mej._4__I have a happy home lifek._4__I am often sorry for the things I dol.__1_I often wish I were someone elsem. _3__My parent(s) expect too much of men._4__My parents trust meo._2__I have a lot of arguments with my parent(s)p._1__There are times when I would like to leave homeq._5__I often have a hard time saying “no”r._4__What my parent(s) think of me is importants._5__I often have trouble expressing my feelingsYour School EnvironmentHow do you currently feel about school? Please check the one that best describes you.( X ) I like it a lot ( ) I think its okay ( ) I don’t like it very much( ) I don’t like it at allPlease read each answer below carefully. For each statement, choose the response from theanswer key that you think best describes your school.
  4. 4. ANSWER KEY1 = strongly disagree2 = disagree3 = not sure4 = agree5 = strongly agreea._3__In our school the students take part in making the rulesb._2__The students are treated too severely/strictly in this schoolc._2__The rules in this school are faird._4__Our school is a nice place to bee._4__I feel I belong at this schoolf._3__Our school is a place where the health of people is importantg._3__I am encouraged to express my own views in classh._2__Our teachers treat us fairlyi._4__When I need extra help I can get itj.__3_My teachers show an interest in me as a personk._4__My teachers expect too much of me at schoolBelow are some questions about bullying. A person is being bullied when another person or group ofpeople 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 alsooccur indirectly by causing a person to be socially isolated through intentional exclusion. It is notbullying when two students about the same strength quarrel or fight.How often have you been bullied in school? Please check the one response that best describes you.ANSWER KEY1 = I have not been bullied in this way2 = once or twice3 = about once a week4 = more than once a weeka. _1__Hit, slapped or pushed youb.__1_Threatened youc._1__Spread rumours or lies about youd.__1_Made sexual jokes, comments or gestures to, or about, youe._1__Purposely left you out of activities, isolated youf.__1_Took or stole personal items from youg.__1_Made fun of (taunted) youANSWER KEY1 = I have not been bullied for this reason2 = once or twice3 = about once a week4 = more than once a weekHow often has someone bullied you in school this term/semester for the reasons listed below?a._1__Made fun of you because of your religion or raceb._1__Made fun of you because of the way you look or talkc.__1_Made fun of you because of your disabilityd.__1_Made fun of you because of your sexual orientation
  5. 5. ANSWER KEY1 = I have not been bullied2 = Yes3 = NoIf you have been bullied, how did you/do you usually react?a. _1__Fightb._1__Shout (yell) at the othersc.__1_Do nothing and wait until they calm downd.__1_Look for somebody to help mee.__1_Try to get awayf.__1_Go to a teacherg._1__Go to my parentsh._1__Go to other adultsi._1__Nothing, there isn’t anything that can be donej.__1_Other (please specify): ______________________________________What caused you excess worry, “nerves” or stress at school last year?Check all the answers that apply to you.( X ) Nothing worries or stresses me( ) I changed schools( ) Too many changes at school( ) Too much pressure from teachers( ) Weird (conflicting) schedules( ) I don’t have enough influence over what I do and when I do it( ) School work is (often) too difficult( ) Not enough help from teachers with school work( ) Too much school work( ) Too much responsibility( ) Deadlines( ) I don’t get enough feedback on how I’m doing( ) I’m bored.( )Conflict with (some) teachers( )Conflict with (some) other students( ) I feel alone (isolated from my fellow students, lonely)( ) I have difficulty speaking with people at school( ) I am physically threatened( ) I’m afraid of violence( ) Thinking about the future( ) I’m being pressured by friends to do what they want( ) I’m afraid of a teacher/teachers( ) I’m often hungry( ) I’m concerned (worried) about grades( ) The way classes are taught( ) Problems with boyfriend/girlfriend( ) Other (please specify): ______________________________________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.( X ) Nothing worries or stresses me( ) A close family member or friend is ill, injured or has died( ) My parents have unrealistic expectations of me( ) Pressure from home to get good marks( ) My parents are over-protective( ) I have begun a new, close relationship
  6. 6. ( ) A close relationship has ended( ) Arguments with someone close to me( ) Arguments with other family members (parents, stepparents, grandparents,brothers, sisters, etc.)( ) Change in living situation (moving to a new home, new roommate, familymember leaving, etc.)( ) My parents are too strict( ) I have trouble balancing school and work responsibilities.( ) I have too much to do( ) I have trouble getting to and from school( ) I have trouble balancing home and school responsibilities( ) Parents split up( ) Parents just don’t bother about me( ) One or both of my parents lost their jobs( ) Fear of street gangs, people with weapons( ) Living by myselfHealth Related Personal Health BehavioursPhysical and Social ActivitiesSome 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 answerfrom the answer key that most closely describes your participation level.ANSWER KEY1 = seldom or never2 = about once a month3 = about once a week4 = 2 or 3 times a week5 = usually every daya._1__Play or practice a league team sport, such as volleyball, basketball, martial arts, soccer,swimming , etc.b.__1_Play games/do activities with friends, such as, basketball, soccer, skateboarding, walking, orbikingc._1__Go to organized classes, such as swimming, dance, or karated._4__Work out or jog for at least 15 minutes at a timee._1__Practice a musical instrument or singingf._2__Go to watch events, such as soccer games, volleyball games, dance presentations or gymnasticdisplaysg. 1 Work at a hobby, such as painting, stamp collecting, model building, drawing,modelling, or actingh._1__Go to dancesi.__3_Play computer games, arcade games with friends or familyj._3__Play computer games, arcade games alonek._1__Watch T.V. or movies; listen to radio/music with friends or familyl._1__Watch T.V. or movies; listen to radio/music alonem. _3__Hang out with family/friends, talk to friends on the phoneo._3__Surfing the internet, e-mailing and chatting online with friendsListed below are some common activities that students do in their out-of-school time. Think aboutthe last months as a guide and for each situation listed below, choose the answer from the answerkey that most closely describes your activity pattern.ANSWER KEY
  7. 7. 1 = none at all2 = about ½ hour3 = about 1 hour4 = about 2 hours5 = about 3 hours6 = about 4 hours7 = about 5 hours8 = about 6 hours9 = about 7 or more hoursHow many hours a day do you usually:a._2__Watch television, including videosb._6__Use a computer (playing games, e-mailing, chatting, surfing the internet)c._5_ Spend time doing school homework outside of school hoursd._1__Listen to music or the radioSpiritual LifeHow 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.( ) Very important ( X ) Fairly important ( ) Not importantHow often do you go to a place of worship (e.g. church, temple, mosque)?Please record your usual practice. Check all responses that apply.( X ) I do not go to a place of worship( ) Rarely (no particular pattern)( ) On special occasions (e.g. weddings, christening)( ) On special days in the religious year (e.g., Hanukkah, Christmas, Easter, Eid)( ) Regularly during certain seasons (e.g., Lent, Advent, Ramadan)( ) Once a month( ) Two or three times a month( ) Every week, or almost every week (this may mean Saturdays or Sundays and/orother weekday services)Which of the following reasons for going to a place of worship apply to you?Please check all that apply.( X ) I do not go to a place of worship( ) I go when I want to( ) I go when someone puts pressure on me to go( ) I go when I feel I ought to go( ) Other (please specify): ______________________________________Please indicate which of the following statements best describes your practice with regard to prayer.Please check the one response that best describes you.( X ) I pray every day, or nearly every day( ) I pray occasionally( ) I do not pray at allLearning English at schoolListed below are some common activities that students do in their school time. Think about the lastyears as a guide and for each situation listed below, choose the answer from the answer key thatmost closely describes your activity pattern.ANSWER KEY1 = strongly disagree2 = disagree3 = not sure
  8. 8. 4 = agree5 = strongly agreea._5__ I like learning English.b.__2_ I don’t like making mistakes when learning English.c._5__ I think learning English is important for my future.d._1__ I don’t think learning English should be compulsory in schools.e._4__ I think I have to understand every word when I listen or read English.f.__1_ My parents don’t think we can learn English in schools.g._2__My parents (mother or father) speak English.h._4__ I see my parents read or get interested in English.i._1__ I don’t like studying English at school.j._3__ I think the teacher is responsible for my motivation.k._4__Speaking English well is like speaking as a native speaker.l.__2_ I try to find patterns in English grammar to help me understand the language.m._2__ I divide the words into parts (suffixes/prefixes) to try to understand the language.o._4__ I pay attention to my mistakes when I’m studying English.p.__3__Writing new words helps to memorise them.q.__2__I revise the things I learn from time to time.r.__5__I want to choose English instead of Spanish to pass the university entrance exam (vestibular).s.__3__ I think that we can only learn English at language schools.t.__5__ When people speak English to me, I understand most of it.u.__4__ When I watch TV, I understand most of it.v.__5__ I can pick a story in the newspaper and read it.I believe my level at English is( ) beginner( ) basic( X ) intermediate( ) FCE or more advanced.( ) Other (please specify): ______________________________________ 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.