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1. What grade are you currently in?
6
7
8
2. How do you spend your after-school free time?
Watching TV or shows on my iPhone and iPad
Participating in an after-school activity
Hanging out with my friends
Doing homework and studying for tests
Other, please specify
3. How many hours of TV or iPad/iPhone shows do you watch every day?
0-1
2-3
4-5
Other, please specify
4. Are you involved in after-school activities this year?
Yes
No
5. What after-school activities are you involved in? Check all that apply.
Soccer
Basketball
Dance
Baseball
Cheer-leading
Playing instruments
Theater
Robotics
Computer
Playing musical instrument
Other, please specify
6. How many hours per week do you spend in after-school activities?
0-3
4-6
More than 7 hours per week
7. What is the main reason that you participate in the after-school activity?
I enjoy doing this activity
I’m good at it
My parents want me to do it
I know that it will benefit me in the future, to get into a good college
My friends participate and I want to do it with them
Other, please specify
8. The skills I learn in my after-school activity help me to gain more friends.
I strongly agree
I somewhat agree
I somewhat disagree
I completely disagree
9. I would recommend my after-school activity to my friends.
I strongly agree
I somewhat agree
I somewhat disagree
I completely disagree
10. My school grades are very important to me.
I strongly agree
I somewhat agree
I somewhat disagree
I completely disagree
11. I work hard to achieve good grades.
I strongly agree
I somewhat agree
I somewhat disagree
I completely disagree
12. Do you complete all of your homework every day?
Always
Most of the times
Rarely
I don’t do my homework
13. Do you study hard for your tests?
Yes. I want to make sure I get a good grade
I try, but sometimes I don’t put in much effort
I don’t really care about my grades
Other, please specify
14. How many times this year have you been referred to the school office for discipline reasons?
0
1-2
3-4
5-6
Other, please specify
15. What was the reason for your referral to the office? Skip if you haven’t been referred to the office.
Late to school
Disobedience to a teacher
Dress-code violation
Cell phone
Cheating on a test
Inappropriate language
Fighting with my peers
Other, please specify
16. Based on your overall grade on your report card, you are a/an:
“A” student, most of my grades are 90-100%
“B” student most of my grades are 80-89%
“C” student most of my grades are 70-79%
“D” student most of my grades are 60- 69% or below
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