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Martha Layne Collins High School Youth Services Center Student Survey
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1.  How old are you? *
2.  What grade are you in? *
3.  What is your race? *
4.  What is your gender? *
5.  Have you ever ridden in a car driven by someone who had been drinking alcohol? *
6. Have you ever been bullied in school? *
7.  Have you ever seriously thought about harming/hurting yourself? *
8.  Have you ever made a plan about how you would harm/hurt yourself? *
9.  Have you ever physically harmed yourself (cutting or burning yourself)? *
10. Have you ever tried cigarette smoking, even one or two puffs? *
11.  Have you ever consumed alcohol? *
12.  During the past 30 days, have you used any illegal drugs? *
13.  Have you ever used marijuana (also called grass or pot)? *
14.  Do you have an adult who you trust to discuss personal problems or concerns with within your school? *
15.  Have you ever been helped by the Youth Services Center (Mrs. Stivers or Mrs. Hayes)? *
16.  During the past 12 months have you been seen by a family doctor or pediatrician? *
17.  During the past 12 months have you been seen by a dentist or dental hygienist? *
18.  During the past 12 months have you had an eye exam by an eye doctor? *
19.  Do you want to know more information about careers or job opportunities? *
20.  If CPR and First aid courses were offered afterschool, would you stay and take the course? *
21.  What do you need assistance with or worry about?  Select all that apply. *
Required
22.  Select the statement(s) that apply to you. *
Required
23.  Select all after school or summer activities that you would be interested in participating in. *
Required
24.  Do you know what your ILP (Individualized Learning Plan) is? *
25.  I use my ILP (Individualized Learning Plan)? *
26.  I know what it means to be College and/or Career ready (CCR)? *
Any comments or suggestions of programs that you would like to see the Youth Services Center to do?
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