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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.

|…...

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