INSTRUCTIONS: Please answer the following questions as accurately and

honestly as possible by filling in the appropriate bubble for each question.

Thank You!!

Name_____________________

Grade______________________

1. Which race/ethnicity best describes you? (Please choose only one.)

Asian / Pacific Islander

Black or African American

Hispanic American

White / Caucasian

Multiple ethnicity / Other (please specify)

2. Do you have a parent or legal guardian that has graduated High School?
Yes

No

Not sure

3. Do you have a parent or Legal guardian that has graduated from any
type of college or technical school after High School?

Yes

No

Not sure

4. Do you feel like you have someone outside of school that can help you
with any of your school work?
Yes

No

Sometimes

5. Do you ever lose or forget to do your homework?

No, never

Yes, but not that often

Yes, on a weekly basis

6. Do you have a designated time in your afternoon or evening for

homework?
Yes

No

Not often, but every now and then

7. Does your household have a computer that you have access too?
Yes

No

Yes, but not often

8. How often do you go to the Snohomish Public Library?

Weekly

A few times a month

Never, or less than a few times a month

9. Do you feel like you have the necessary resources at home to complete
your homework (computers, books, support from members of the
household,ect.)?
Yes

No

Sometimes, but not a lot

10. Do you find it hard to focus on your schoolwork at school?

Yes

No

Sometimes, but not often

11. Do you find it hard to focus on your schoolwork at home?

Yes

No

Sometimes, but not often

12. Do you keep a calendar or some other kind of organizational tool to

help keep yourself organized when it comes to schoolwork?
Yes

No

Sometimes, but not often

If yes, what do you use?

13. How many hours outside of school do you spend on school work?
0-2 hours

3-5 hours

6 or more

I don't do my homework

14. Are you involved in any clubs or activities outside of school hours?
Yes

No

Not at this time but I have been in the past

15. Are you involved in any clubs or activities that are not involved with
school?
Yes

No

Not at this time but I have been in the past

16. How many hours weekly are you involved in organized clubs or
activities outside of school?

0 hours

1-4 hours

5-7 hours

More than 7 hours

17. Has transportation ever been an issue for you in regards to getting to
school or getting to activities outside of school?
Yes

No

Very rarely

18. Do you feel like you are supported by your family when it comes to
school?
Yes

No

Sometimes, but not as much as I would like

19. Do you feel like you have the proper support at school from your
teachers and staff?
Yes

No

Sometimes, but not as much as I would like

20. What would make your experience at school a more positive one?
(Please take time to give a few examples)

NOTICE FOR TEACHER:

Will you please hand out these envelopes to the students during your Patriot
Period? They were a selected group of students to take a survey in January
that I am putting out for part of my internship requirements and in the
envelope is a brochure that gives the parents information regarding this
survey. Thank you