Sex: Male Female    Race or Ethnicity: White Non-Hispanic African-American Non-Hispanic Native American or Alaskan Native Hispanic Asian or Pacific Islander Other
Number of your children enrolled on the campus: 1 2 3 4 5 6 7 8 9 10 11 12

Select the grade of the children you have at school. (Select all that apply.):
Pre-K   Kindergarten   1st   2nd   3rd   4th   5th
6th   7th   8th   9th   10th   11th   12th

Are there particular places at school where your child doesn't feel safe? (Select all that apply.):
Classrooms   Lunchrooms   Playground   Parking Lot   Restrooms
Are there particular times at school where your child doesn't feel safe? (Select all that apply.)
Before school   During class   During Lunch   After School   All Day
 

This school year has your child had any of his/her possessions stolen at school? No Yes
This school year has anything been taken from your child by force, or threats? No Yes
This school year has someone physically threatened, attacked, or hurt your child? No Yes Many
This school year has someone verbally threatened your child? No Yes 1+
This school year has someone made sexual advances or attempted sexual assault? No Yes 1+
This school year has someone sexually assaulted your child? No Yes 1+
If yes to any of the above group, where did this happen? (Select all that apply.)
At School   To/From School   School Bus   School Activity   Other
 

Do you feel there is a process in place for students to report alleged abuse? Yes No
Do you feel the campuses follow up on the reports of alleged abuse? Yes No

This school year did your children discuss seeing someone at school with a weapon? No Yes
If yes, please specify what kind of weapon they saw. (Select all that apply.)
Gun   Knife   Scissors   Other

How serious are the following problems on campus?
Vandalism Don't Know Not Serious Serious Very Serious    Alcohol Don't Know Not Serious Serious Very Serious    Tobacco Don't Know Not Serious Serious Very Serious
Drugs Don't Know Not Serious Serious Very Serious    Weapons Don't Know Not Serious Serious Very Serious    Racial Issues Don't Know Not Serious Serious Very Serious

In your opinion, what are the three major problems at this campus right now?