Your Views on Safety and Support

Purpose of the Survey

This survey provides an opportunity to share your thoughts on what you feel is needed to ensure
that you and your school can be as safe, healthy and supportive as possible.
You do not have to fill out ALL QUESTIONS in this survey if you do not want to. However, everyone’s
views are important. Please understand that this questionnaire is completely confidential.

Name: João Gabriel Rocha Couto Gomes
Group: 1° F

Your Background
In your opinion, what kind of grades (marks) do you usually get in English?
Please check the one response that best describes you.

A) Not very good B) Fair C) Average D) Very good X) Excellent

What do you think you will be doing when you finish high school at Dom Silvério?

A) Law
B) Medicine
C) Engineer
D) Architect
E) Economist
F) Psychologist
G) Web Developer
H) Uncertain
X) Other: _Programmer____________________________________

People live in different types of families. Sometimes people live with just one parent, sometimes they
live with each parent but in different homes, or sometimes they live in different situations.
If you live in only one home, or where you live most of the time, please check all the people you live
with.

( X ) Mother ( X ) Father ( ) Stepmother ( ) Stepfather ( ) Foster family or group home
( X ) Brothers (include step, half and foster brothers)Sisters (include step, half and foster sisters)
( ) Grandmother ( ) Grandfather ( ) Other relatives ( ) Other people
( ) I live on my own

Are you responsible for anyone at home on either a part time or full time basis (e.g. a sick or elderly
relative, parent, a younger brother or sister, child)?
( )Yes ( X ) No

How long have you lived in Belo Horizonte?
( X ) Since birth ( ) More than 5 years ( ) 1-2 years ( ) Less than one year

Your Health
In your opinion, how would you describe your health? Please check the one response that best
describes you.
( ) Poor ( ) Fair ( ) Good ( X ) Very good ( ) Excellent

Do you have a disability, long-term illness (e.g. leukemia) or chronic condition (e.g. diabetes,
asthma)? Please check the one response that best describes you.
( X )Yes ( ) No

If you have a disability, long-term illness or chronic condition, please check the relevant category
below. Please check all responses that apply to you.

( ) I do not have such a condition.
( ) Learning disability
( ) Physical disability
( ) Emotional disability
( ) Allergies (food)
( ) Allergies (respiratory)
( X ) Asthma
( ) Diabetes
( ) Other (please specify): ______________________________________

Does your disability, long-term illness or chronic condition affect your attendance and participation
at school? Please check the one response that best describes you.
I do not have such a condition
( )Yes ( X ) No

What would you like to do in the next year to improve or maintain your health?
Please check all the responses that apply to you.
( ) Drink less coffee or tea
( X ) Eat healthier foods
( ) Be more physically active
( ) Remove a major source of worry, nerves or stress from my life
( ) Learn to cope better with worry, nerves or stress
( ) Spend less hours on Internet
( ) Quit smoking or smoke less
( ) Be less dependent of Mobile phones
( ) Cut down on painkillers, sleeping or calming medications
( ) Lose weight
( ) Gain weight
( ) Skip fewer meals
( ) Learn to be more assertive
( ) Learn to control anger (better)
( ) Learn to communicate (better)
( ) Learn to deal with relationships
( ) Learn to manage time (better)
( ) Learn to manage money (better)
( ) Deal/cope with an eating disorder
( ) Deal/cope with bullying
( ) Deal/cope with violence
( ) Nothing

What is stopping you from making this change? Please check all the responses that apply to you.
( ) Nothing
( ) Problem isn’t serious, there’s no rush
( ) My boyfriend/girlfriend is not supportive
( ) Difficult situation at home
( ) Not enough time
( ) Not enough energy
( ) Not enough money
( ) I’m too depressed (sad)
( X ) I don’t know how to get started

( ) No encouragement or help from family and friends
( ) No encouragement or help from school
( ) It is too hard
( ) I don’t want to change my ways
( ) I’m not sure I really can make a difference
( ) I have too much stress right now
( ) I’m afraid of the unknown (future)
( ) I’m unsure of myself (lack self-confidence)
( ) I don’t know what is stopping me
( ) It is not important to me
( ) I don’t feel like it

How many hours do you usually sleep at night?
( ) 0 to 4 hours ( ) 5 to 6 hours ( X ) 7 to 8 hours ( ) 9 hours or more

Your Feelings
For each statement below, choose the response from the answer key that best describes yourself.
Place the corresponding number on the line beside each statement.

ANSWER KEY
1 = strongly disagree
2 = disagree
3 = not sure
4 = agree
5 = strongly agree

a._4__I have trouble making decisions
b._5__I have confidence in myself (I am sure of myself)
c._3__I would change how I look, if I could
d._3__I have usually found that what is going to happen will happen, regardless of my plans
e._3__I usually behave according to my beliefs
f.__4_My life is full of meaning and purpose
g._5__On the whole, it seems to me that things turn out the way they should
h._4__I like myself
i.__3_My parents understand me
j._4__I have a happy home life
k._4__I am often sorry for the things I do
l.__1_I often wish I were someone else
m. _3__My parent(s) expect too much of me
n._4__My parents trust me
o._2__I have a lot of arguments with my parent(s)
p._1__There are times when I would like to leave home
q._5__I often have a hard time saying “no”
r._4__What my parent(s) think of me is important
s._5__I often have trouble expressing my feelings

Your School Environment
How do you currently feel about school? Please check the one that best describes you.
( X ) I like it a lot ( ) I think its okay ( ) I don’t like it very much
( ) I don’t like it at all

Please read each answer below carefully. For each statement, choose the response from the
answer key that you think best describes your school.

ANSWER KEY
2 = disagree
3 = not sure
4 = agree
5 = strongly agree

a._3__In our school the students take part in making the rules
b._2__The students are treated too severely/strictly in this school
c._2__The rules in this school are fair
d._4__Our school is a nice place to be
e._4__I feel I belong at this school
f._3__Our school is a place where the health of people is important
g._3__I am encouraged to express my own views in class
h._2__Our teachers treat us fairly
i._4__When I need extra help I can get it
j.__3_My teachers show an interest in me as a person
k._4__My teachers expect too much of me at school

Below are some questions about bullying. A person is being bullied when another person or group of
people says or does nasty and unpleasant things to him/her such as taunting, threatening, hitting,
and stealing.
It is also bullying when a person is teased repeatedly in a way he/she doesn’t like. Bullying may also
occur indirectly by causing a person to be socially isolated through intentional exclusion. It is not
bullying when two students about the same strength quarrel or fight.

How often have you been bullied in school? Please check the one response that best describes you.
ANSWER KEY
1 = I have not been bullied in this way
2 = once or twice
3 = about once a week
4 = more than once a week

a. _1__Hit, slapped or pushed you
b.__1_Threatened you
c._1__Spread rumours or lies about you
d.__1_Made sexual jokes, comments or gestures to, or about, you
e._1__Purposely left you out of activities, isolated you
f.__1_Took or stole personal items from you
g.__1_Made fun of (taunted) you

ANSWER KEY
1 = I have not been bullied for this reason
2 = once or twice
4 = more than once a week

How often has someone bullied you in school this term/semester for the reasons listed below?
a._1__Made fun of you because of your religion or race
b._1__Made fun of you because of the way you look or talk
c.__1_Made fun of you because of your disability
d.__1_Made fun of you because of your sexual orientation

ANSWER KEY
1 = I have not been bullied
2 = Yes
3 = No

If you have been bullied, how did you/do you usually react?
a. _1__Fight
b._1__Shout (yell) at the others
c.__1_Do nothing and wait until they calm down
d.__1_Look for somebody to help me
e.__1_Try to get away
f.__1_Go to a teacher
g._1__Go to my parents
h._1__Go to other adults
i._1__Nothing, there isn’t anything that can be done
j.__1_Other (please specify): ______________________________________

What caused you excess worry, “nerves” or stress at school last year?
Check all the answers that apply to you.
( X ) Nothing worries or stresses me
( ) I changed schools
( ) Too many changes at school
( ) Too much pressure from teachers
( ) Weird (conflicting) schedules
( ) I don’t have enough influence over what I do and when I do it
( ) School work is (often) too difficult
( ) Not enough help from teachers with school work
( ) Too much school work
( ) Too much responsibility
( ) Deadlines
( ) I don’t get enough feedback on how I’m doing
( ) I’m bored.
( )Conflict with (some) teachers
( )Conflict with (some) other students
( ) I feel alone (isolated from my fellow students, lonely)
( ) I have difficulty speaking with people at school
( ) I am physically threatened
( ) I’m afraid of violence
( ) Thinking about the future
( ) I’m being pressured by friends to do what they want
( ) I’m afraid of a teacher/teachers
( ) I’m often hungry
( ) I’m concerned (worried) about grades
( ) The way classes are taught
( ) Problems with boyfriend/girlfriend

What caused you excess worry, “nerves” or stress at home or outside school in the last six months?
Check all the answers that apply to you.
( X ) Nothing worries or stresses me
( ) A close family member or friend is ill, injured or has died
( ) My parents have unrealistic expectations of me
( ) Pressure from home to get good marks
( ) My parents are over-protective
( ) I have begun a new, close relationship

( ) A close relationship has ended
( ) Arguments with someone close to me
( ) Arguments with other family members (parents, stepparents, grandparents,
brothers, sisters, etc.)
( ) Change in living situation (moving to a new home, new roommate, family
member leaving, etc.)
( ) My parents are too strict
( ) I have trouble balancing school and work responsibilities.
( ) I have too much to do
( ) I have trouble getting to and from school
( ) I have trouble balancing home and school responsibilities
( ) Parents split up
( ) Parents just don’t bother about me
( ) One or both of my parents lost their jobs
( ) Fear of street gangs, people with weapons
( ) Living by myself

Health Related Personal Health Behaviours
Physical and Social Activities

Some common activities are listed below. How often do you take part in each of these activities?
Think about the last month as a guide and for each of the activities listed below, choose the answer
from the answer key that most closely describes your participation level.

ANSWER KEY
1 = seldom or never
2 = about once a month
4 = 2 or 3 times a week
5 = usually every day

a._1__Play or practice a league team sport, such as volleyball, basketball, martial arts, soccer,
swimming , etc.
b.__1_Play games/do activities with friends, such as, basketball, soccer, skateboarding, walking, or
biking
c._1__Go to organized classes, such as swimming, dance, or karate
d._4__Work out or jog for at least 15 minutes at a time
e._1__Practice a musical instrument or singing
f._2__Go to watch events, such as soccer games, volleyball games, dance presentations or gymnastic
displays
g. 1 Work at a hobby, such as painting, stamp collecting, model building, drawing,
modelling, or acting
h._1__Go to dances
i.__3_Play computer games, arcade games with friends or family
j._3__Play computer games, arcade games alone
k._1__Watch T.V. or movies; listen to radio/music with friends or family
l._1__Watch T.V. or movies; listen to radio/music alone
m. _3__Hang out with family/friends, talk to friends on the phone
o._3__Surfing the internet, e-mailing and chatting online with friends

Listed below are some common activities that students do in their out-of-school time. Think about
the last months as a guide and for each situation listed below, choose the answer from the answer
key that most closely describes your activity pattern.

ANSWER KEY

1 = none at all
2 = about ½ hour
3 = about 1 hour
4 = about 2 hours
5 = about 3 hours
6 = about 4 hours
7 = about 5 hours
8 = about 6 hours
9 = about 7 or more hours

How many hours a day do you usually:
a._2__Watch television, including videos
b._6__Use a computer (playing games, e-mailing, chatting, surfing the internet)
c._5_ Spend time doing school homework outside of school hours
d._1__Listen to music or the radio

Spiritual Life
How important is it for you to have a spiritual part to your life (however you choose to define
“spiritual”)? Please check the one response that best describes you.
( ) Very important ( X ) Fairly important ( ) Not important

How often do you go to a place of worship (e.g. church, temple, mosque)?
Please record your usual practice. Check all responses that apply.
( X ) I do not go to a place of worship
( ) Rarely (no particular pattern)
( ) On special occasions (e.g. weddings, christening)
( ) On special days in the religious year (e.g., Hanukkah, Christmas, Easter, Eid)
( ) Regularly during certain seasons (e.g., Lent, Advent, Ramadan)
( ) Once a month
( ) Two or three times a month
( ) Every week, or almost every week (this may mean Saturdays or Sundays and/or
other weekday services)

Which of the following reasons for going to a place of worship apply to you?
Please check all that apply.
( X ) I do not go to a place of worship
( ) I go when I want to
( ) I go when someone puts pressure on me to go
( ) I go when I feel I ought to go

Please indicate which of the following statements best describes your practice with regard to prayer.
( X ) I pray every day, or nearly every day
( ) I pray occasionally
( ) I do not pray at all

Learning English at school
Listed below are some common activities that students do in their school time. Think about the last
years as a guide and for each situation listed below, choose the answer from the answer key that
most closely describes your activity pattern.
ANSWER KEY
2 = disagree
3 = not sure

4 = agree
5 = strongly agree

a._5__ I like learning English.
b.__2_ I don’t like making mistakes when learning English.
c._5__ I think learning English is important for my future.
d._1__ I don’t think learning English should be compulsory in schools.
e._4__ I think I have to understand every word when I listen or read English.
f.__1_ My parents don’t think we can learn English in schools.
g._2__My parents (mother or father) speak English.
h._4__ I see my parents read or get interested in English.
i._1__ I don’t like studying English at school.
j._3__ I think the teacher is responsible for my motivation.
k._4__Speaking English well is like speaking as a native speaker.
l.__2_ I try to find patterns in English grammar to help me understand the language.
m._2__ I divide the words into parts (suffixes/prefixes) to try to understand the language.
o._4__ I pay attention to my mistakes when I’m studying English.
p.__3__Writing new words helps to memorise them.
q.__2__I revise the things I learn from time to time.
r.__5__I want to choose English instead of Spanish to pass the university entrance exam (vestibular).
s.__3__ I think that we can only learn English at language schools.
t.__5__ When people speak English to me, I understand most of it.
u.__4__ When I watch TV, I understand most of it.
v.__5__ I can pick a story in the newspaper and read it.

I believe my level at English is
( ) beginner
( ) basic
( X ) intermediate
( ) FCE or more advanced.

Thanks for taking the time to complete this questionnaire.
You have played an important role in helping your school
to become a safer, healthier and more caring place.

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