07 EYT Survey A (Ages 10-13)

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  • Introduction

    You are being asked to fill out this survey because you are part of the [Empowering Youth Today (EYT) Program]. This survey asks you what you think about your relationships with other people, your future goals and beliefs. You can choose to fill out the survey or not fill out the survey. If you choose not to fill out the survey, it will not affect you in any way. If you fill out the survey, you can skip any question you do not want to answer. You can change your mind about filling out the survey at any time.

    Your answers will help us to make [EYT] better. No one will know your answers, including parents and teachers. Please do not write your name anywhere on this survey. There are no right or wrong answers. Please read each question carefully. Clearly mark your answer to each question. Mark only one answer for each question or each row in a table unless the question says to select more than one response.
  • 9101112131415161718 or older
  • 5. These questions are about your future. Please circle the response that best describes your feelings.

    MARK () ONE ANSWER FOR EACH ITEM
  • Not important at allSomewhat importantVery importantExtremely important
  • Not important at allSomewhat importantVery importantExtremely important
  • Not important at allSomewhat importantVery importantExtremely important
  • Drop out before finishing high schoolGraduate from high schoolFinish a trade/vocational schoolGraduate from a junior collegeGraduate from collegeGraduate from a professional (doctor, lawyer), Masters, or PhD program
  • 7. These statements describe a person who may or may not be like you. Please circle the response that tells how well the statement describes you.

    MARK () ONE ANSWER FOR EACH ITEM
  • Not at all like meA little like meMostly like meVery much like me
  • Not at all like meA little like meMostly like meVery much like me
  • Not at all like meA little like meMostly like meVery much like me
  • 8. How important are each of the following to you in your life?

    MARK () ONE ANSWER FOR EACH ITEM
  • Not importantSomewhat importantQuite importantExtremely important
  • Not importantSomewhat importantQuite importantExtremely important
  • Not importantSomewhat importantQuite importantExtremely important
  • Not importantSomewhat importantQuite importantExtremely important
  • Not importantSomewhat importantQuite importantExtremely important
  • 9. Please circle the response that shows how much you agree or disagree with the following statements.

    MARK () ONE ANSWER FOR EACH ITEM
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • 10. Think about your relationship with others in this program. Next to each statement below, please circle the response that best applies to your relationship with or involvement with this group.

    MARK () ONE ANSWER FOR EACH ITEM
  • NeverRarelyAbout half the timeMost of the timeAlways
  • NeverRarelyAbout half the timeMost of the timeAlways
  • NeverRarelyAbout half the timeMost of the timeAlways
  • 11. Please circle the response that shows how strongly do you agree or disagree with the following statements.

    MARK () ONE ANSWER FOR EACH ITEM
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • 12. Please circle the response that shows how much you agree or disagree with the following statements.

    MARK () ONE ANSWER FOR EACH ITEM
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • 13. Please circle the response that shows how much you agree or disagree with the following statements. In a healthy relationship, I have the right:

    MARK () ONE ANSWER FOR EACH ITEM
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • 14. Please circle the response that shows how much you agree or disagree with the following statements. In a healthy relationship, I have the responsibility:

    MARK () ONE ANSWER FOR EACH ITEM
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • 15. Please circle the response that shows how much you agree or disagree with the following statements.

    MARK () ONE ANSWER FOR EACH ITEM
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree
  • Strongly DisagreeDisagreeAgreeStrongly Agree