Section 1 of 1
Student Survey for Safety and Connection
Dr. Lori Desautels ( Based upon the framework of Applied Educational Neuroscience)
© Revelations in Education 2021
© Revelations in Education 2021
What grade are you in?
What grade are you in?
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7th grade
8th grade
Freshman
Sophomore
Junior
Senior
Option 7
Option 8
Option 9
Option 10
Option 11
Option 12
Other:
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Do you feel you get enough sleep most nights?
Do you feel you get enough sleep most nights?
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Yes
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Explain if you feel comfortable
Explain if you feel comfortable
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Are you getting some exercise each day or a few times a week?
Are you getting some exercise each day or a few times a week?
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Explain if you feel comfortable
Explain if you feel comfortable
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Do you feel you drink plenty of water each day (4-6 glasses)?
Do you feel you drink plenty of water each day (4-6 glasses)?
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Explain if you feel comfortable
Explain if you feel comfortable
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Do you spend time outdoors?
Do you spend time outdoors?
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Explain if you feel comfortable
Explain if you feel comfortable
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Have you created relationships with adults you trust this year?
Have you created relationships with adults you trust this year?
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Explain if you feel comfortable
Explain if you feel comfortable
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Have you created good relationships with other students this year?
Have you created good relationships with other students this year?
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Explain if you feel comfortable
Explain if you feel comfortable
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This school is a safe and secure place.
This school is a safe and secure place.
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Explain if you feel comfortable
Explain if you feel comfortable
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I feel connected to a few of the teachers in my building.
I feel connected to a few of the teachers in my building.
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Explain if you feel comfortable
Explain if you feel comfortable
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I feel everyone is treated with respect, even though we all make mistakes and have off days.
I feel everyone is treated with respect, even though we all make mistakes and have off days.
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Explain if you feel comfortable
Explain if you feel comfortable
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I feel everyone in the classroom seems relaxed and we are learning.
I feel everyone in the classroom seems relaxed and we are learning.
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Yes
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Explain if you feel comfortable
Explain if you feel comfortable
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Are you using strategies this year to help keep your emotions calm?
Are you using strategies this year to help keep your emotions calm?
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Explain if you feel comfortable
Explain if you feel comfortable
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Do you have someone in your family you can go to when you are upset?
Do you have someone in your family you can go to when you are upset?
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Explain if you feel comfortable
Explain if you feel comfortable
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Do you feel you resolve conflicts peacefully?
Do you feel you resolve conflicts peacefully?
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Explain if you feel comfortable
Explain if you feel comfortable
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Do you feel the adults in the school know how to resolve conflicts peacefully?
Do you feel the adults in the school know how to resolve conflicts peacefully?
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Explain if you feel comfortable
Explain if you feel comfortable
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Do you feel you stand up for yourself when you need to?
Do you feel you stand up for yourself when you need to?
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Explain if you feel comfortable
Explain if you feel comfortable
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Do you know how to care for yourself when people are picking on you?
Do you know how to care for yourself when people are picking on you?
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Explain if you feel comfortable
Explain if you feel comfortable
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Do some or all of these interfere with your learning and how you feel each day?
Do some or all of these interfere with your learning and how you feel each day?
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Date
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anger
fighting
drugs/alcohol/vaping
worries about my family/parents
sadness about a loss of a family member or friend
not getting along with others
people bullying me
stress
feeling sad most of the time
my ability to get along with my teachers
not having enough to eat
fear of coming to school
fear of making mistakes
fear of being emotionally hurt
hear of being physically hurt
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My teacher and the other adults in my school make sure that I am feeling successful, and when I am not, they help me!
My teacher and the other adults in my school make sure that I am feeling successful, and when I am not, they help me!
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Explain if you feel comfortable
Explain if you feel comfortable
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In my school teachers emphasize our strengths and pay attention to our interests. They want to know what I like and what I am good at!
In my school teachers emphasize our strengths and pay attention to our interests. They want to know what I like and what I am good at!
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Explain if you feel comfortable
Explain if you feel comfortable
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My school and teachers pay attention to how I feel and that I feel safe and connected to others when I am at school.
My school and teachers pay attention to how I feel and that I feel safe and connected to others when I am at school.
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Explain if you feel comfortable
Explain if you feel comfortable
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I feel that learning about my brain and nervous system has been or would be helpful.
I feel that learning about my brain and nervous system has been or would be helpful.
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Explain if you feel comfortable
Explain if you feel comfortable
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What are two or three things you feel would help you feel successful at school?
What are two or three things you feel would help you feel successful at school?
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What are two or three changes you would like to see in your school?
What are two or three changes you would like to see in your school?
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What is something you wish your teachers knew or understood about you?
What is something you wish your teachers knew or understood about you?
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