6-8 Needs Assessment

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Who Am I?

Please fill out this survey to help me get to know you a little better.

FIRST NAME________________________LAST NAME_________________

GRADE_________ HOMEROOM __________________________

Read each sentence. Put a circle around the number that shows how you think and feel right now. If you’d like to give me
more information about the statement, write below the question.
1 = Strongly agree
2 = Agree somewhat
3 = Agree
4= Disagree somewhat
5= Strongly disagree
Strongly Agree Strongly Disagree
 I like who I am Agree 1 2 3 4 5

 I have someone to talk to about my feelings 1 2 3 4 5

 I know how to make friends 1 2 3 4 5

 I am a good friend to others 1 2 3 4 5

 My classmates treat me with respect 1 2 3 4 5

 I still feel a lot of grief about someone I love dying 1 2 3 4 5

 I get along well with my family 1 2 3 4 5

 My anger gets me in trouble 1 2 3 4 5

 I have my temper under control 1 2 3 4 5

 I know how to deal with bullies 1 2 3 4 5

 If someone teases me, I can handle it 1 2 3 4 5

 I am a responsible person 1 2 3 4 5
 I have good attendance 1 2 3 4 5
Strongly Agree Strongly Disagree
Agree
 I am never tardy 1 2 3 4 5

 Last year, I had less than 3 office referrals 1 2 3 4 5

 I know how to ask for help when I need it 1 2 3 4 5

 I know how to study for tests 1 2 3 4 5

 I always do my homework 1 2 3 4 5

 Someone I care about has a serious illness 1 2 3 4 5

 I was proud of my grades last year 1 2 3 4 5

 I am a leader 1 2 3 4 5

 I have goals for my future 1 2 3 4 5

 I am new at this school 1 2 3 4 5

 Is there anything else you’d like Ms. Moundros to know about you?

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