MOE - TTLNA PRIMARY 3 School Form / Class Student Name 1. Student PIN 1. Are you boy or girl?? 0- 1-Boy 2-Girl When is your birthday? 3. What language do you speak most often at home? 0- 1-English 2-Spanish 3-Other 4. How many parents do you live with? 0- 1-None 2-One 3-Two 5. How many people live in your house? 0- 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 or more 6. How many books are there in your home 0- 1-None of very few 2-Enough to fill one shelf (11 - 25 books) 3-Enough to fill one book case (26 - 100 books) 4-Enough to fill two bookcases (101 - 200 books) 5-Enough to fill three or more bookcases (more than 200) 7. Do you have any of these things at your home? (All that apply) Computer or tablet Your own cell phone Study desk/table for you use Your own room Internet connection 8. How often are you absent from school? 0- 1-More than once a week 2-Once a week 3-Once every two weeks 4-Once a month 5-Never or almost never 9. How often do you feel this way when you arrive at school? 9a. I feel tired 0- 1-Every day 2-Almost every day 3-Sometimes 4- Almost never 5-Never 9b. I feel hungry 0- 1-Every day 2-Almost every day 3-Sometimes 4- Almost never 5-Never 10. How often do you eat breakfast at home on school days? 0- 1-Every day 2-Almost every day 3-Sometimes 4-Almot Never 5-Never 11. How often do you use a computer or tablet in each of these places for schoolwork? 11a. At home 0- 1-Every day or almost every day 2-Once or twice a week 3-Once or twice a month 4-Never or almost never 11b. At school 0- 1-Every day or almost every day 2-Once or twice a week 3-Once or twice a month 4-Never or almost never 11c. Some other place 0- 1-Every day or almost every day 2-Once or twice a week 3-Once or twice a month 4-Never or almost never 12. How much time do you spend using a computer or tablet to do these activities? 12a. Finding and reading information 0- 1-No time 2-30 minutes or less 3-More than 30 minutes 12b. Preparing class presentations 0- 1-No time 2-30 minutes or less 3-More than 30 minutes 13. How much time do you spend each day using a computer or tablet for any of the following activities? 13a. Playing games 0- 1-No time 2-30 minutes or less 3-30minutes to 1 hour 4-1 hour to 2 hours 5-2 hours or more 13b. Watching videos 0- 1-No time 2-30 minutes or less 3-30minutes to 1 hour 4-1 hour to 2 hours 5-2 hours or more 13c. Chatting 0- 1-No time 2-30 minutes or less 3-30minutes to 1 hour 4-1 hour to 2 hours 5-2 hours or more 13d. Surfing the Internet 0- 1-No time 2-30 minutes or less 3-30minutes to 1 hour 4-1 hour to 2 hours 5-2 hours or more 14. How often do you recieve help with your school work from a family member, friend or tutor? 0- 1-Never 2-About once or twice a year 3-About once or twice a month 4-About once or twice a week 5-Every day or almost every day 15. How much do you agree or disagree with these statements about your school? 15a. I like this school 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15b. Proud to be a student of this school 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15c. I feel like I belong at this school 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15d. Teachers at this school are fair to me 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15e. I usually work hard on my school work 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15f. I want to learn as much as i can at school 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15g. I learn important things at this school 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15h. It is important that i come to school every day 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15i. i get to do interesting things at school 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15j. I help my class make decisions at school 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15k.Teachers and other adults at this school expect me to succeed 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 15l. Teachers and other adults at this school provide me the support I need to succeed 0- 1-Strongly disagree 2-Disagree 3-Somewhat disagree 4-somewhat agree 5-Agree 16. Do you agree or disagree with the following statements? 16a. I stop and think before doing anything when I get angry? 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 16b. I work out disagreements with other students by talking with them 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 16c. I know how to disagree without starting an argument or a fight 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 16d. I know how to decide right from wrong 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 16e. I can control myself when I am upset 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 17. How much does of the following statements describe you? 17a. I like complex problems more than easy problems 0- 1-Not at all like me 2-A little bit like me 3-Somewhat like me 4-Quite a bit like me 5-Very much like me 17b. I like activities that challenge my thinking abilities 0- 1-Not at all like me 2-A little bit like me 3-Somewhat like me 4-Quite a bit like me 5-Very much like me 17c. I enjoy situations where i will have to think about something 0- 1-Not at all like me 2-A little bit like me 3-Somewhat like me 4-Quite a bit like me 5-Very much like me 17d. I enjoy thinking about new solutions to problems 0- 1-Not at all like me 2-A little bit like me 3-Somewhat like me 4-Quite a bit like me 5-Very much like me 18. In this school year, how often have you done each of the following? 18a. I started working on assignments right away rather than waiting on last minute 0- 1-Never or hardly ever 2-Less than half the time 3-About half the time 4-More than half the time 5-All or almost all of the time 18b. I paid attention and resisted distractions 0- 1-Never or hardly ever 2-Less than half the time 3-About half the time 4-More than half the time 5-All or almost all of the time 18c. I stayed on tasks without reminders from my teacher 0- 1-Never or hardly ever 2-Less than half the time 3-About half the time 4-More than half the time 5-All or almost all of the time 18d. i paid attention in class even when i was not interested 0- 1-Never or hardly ever 2-Less than half the time 3-About half the time 4-More than half the time 5-All or almost all of the time 19. How much do you agree or disagree withe the following statements about Mathematics? 19a. I usually do well in methematics 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 19b. Mathematics is harder for me than for many of my classmates 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 19c. I am just not good at mathematics 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 19d. I learn things quickly in mathematics 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 19e. Mathematics makes me nervous 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 19f. I am good at working with difficult mathematics problems 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 19g. My teacher tells me i am good at mathematics 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 19h. Mathematics is harder for me than any other subject 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 19i. Mathematics makes me confused 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 20. In this school year how often did the following things happen in your math class? 20a. My teacher used computers 0- 1-Never or hardly ever 2-Less than half the time 3-About half the time 4-More than half the time 5-All or almost all of the time 20b.My teacher required us to use computers 0- 1-Never or hardly ever 2-Less than half the time 3-About half the time 4-More than half the time 5-All or almost all of the time 21 How much do you agree of disagree with the following statements about reading? 21a. I usually do well in reading 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 21b. Reading is easy for me 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 21c. I have trouble reading stories with difficult words 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 21d. Reading is harder for me that my classmates 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 21e. Reading is harder for me than any other subject 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 21f. i am just not good at reading 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 21g. My teacher tells me I am good at reading 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 21h. I learn to read new words quickly 0- 1-Strongly Disagree 2-Disagree 3-Agree 4-Strongly Agree 22. How often does your teacher ask you to discuss new or difficult vocabulary? 0- 1-Never 2-About once a year 3-About once or twice a month 4-About once or twice a week 5-Every day or almost every day Submit
