1. Is the student in question a male or female? (required)

male    female

2. What is the age of the student? (required)

6-11    12-14    15-21

3. What is the student's ethnicity? (required)

African American    Caucasian    Other Minority

4. Is English a second language for the student?

yes    no    unknown

5. Is the student receiving special services?

yes    no    unknown

6. Does the student have specific problems in reading?

yes    no    unknown

7. Does the student have ongoing problems in most school subjects?

yes    no    unknown

8. Has the student been retained in a grade?

yes    no    unknown

9. Does the student like school?

yes    no    unknown

10. Does the student get along well with teachers?

yes    no    unknown

yes    no    unknown

12. Does the student tend to get into trouble at school?

yes    no    unknown

13. Does the student seem to be extremely shy or withdrawn?

yes    no    unknown

14. Is the student ever bullied by other students?

yes    no    unknown

15. Does the student tend to bully other students?

yes    no    unknown

16. Does the student expect to do well in school?

yes    no    unknown

17. Does the student feel accepted by faculty and staff?

yes    no    unknown

18. Does the student have any physical or medical problems?

yes    no   unknown

19. Is the student absent from school more than twice a month?

yes    no    unknown

20. Does the student work at a job for more than 15 hours per week?

yes    no    unknown

21. Does the student participate in extra-curricular activities during or after school?

yes    no    unknown

22. Does the student get along well with other students?

yes    no    unknown

23. Is the student suspected of being involved in alcohol or drug use?

yes    no   unknown

24. Is the student suspected of being a member of a gang?

yes    no    unknown

25. Does the family respond with action as needed when contacted by the school?

yes    no    unknown