Student Self-Reflection Survey

1. Email address *

The purpose of this Self-Reflection Survey is for students to

explore their capacity to integrate skills, attitudes, and behaviors
to deal effectively and ethically with daily tasks and challenges.

2. First Name

3. Last Name

Skip to question 3.

Self Awareness

Self Awareness is the ability to accurately recognize one's own

emotions, thoughts, and values and how that influences
behavior. This includes the ability to accurately assess one's
strengths and limitations, with a well-grounded sense of
confidence, optimism, and a "growth mindset".

4. I am able to identify, recognize and name my emotions in the moment.

Mark only one oval.

1 2 3 4

Never Always

5. I recognize the relationship between my feelings and my reactions to people and situations.
Mark only one oval.

1 2 3 4

Never Always
 6. I can see the big picture in a difficult situation.
Mark only one oval.

1 2 3 4

Never Always

7. I know and am realistic about my strengths and limitations.

Mark only one oval.

1 2 3 4

Never Always

8. I encourage others to tell me how my actions have affected them.

Mark only one oval.

1 2 3 4

Never Always

9. I know how my own needs and values affect the decisions I make.
Mark only one oval.

1 2 3 4

Never Always

10. I believe I determine my own potential and can use it to influence others.
Mark only one oval.

1 2 3 4

Never Always

11. I feel confident that I can handle whatever comes along while remaining calm and relaxed.
Mark only one oval.

1 2 3 4

Never Always

12. I believe that most experiences help me learn and grow.

Mark only one oval.

1 2 3 4

Never Always
13. I can see the positive even in negative situations.
Mark only one oval.

1 2 3 4

Never Always

14. How do you prefer to take in information?

Mark only one oval.

1 2

I like to describe things in a specific, I like to describe things in a figurative,

literal way poetic way

15. Mark only one oval.

1 2

I focus on the reality of how things I imagine the possibilities of how things
are could be

16. Mark only one oval.

1 2

I pay attention to concrete facts and I notice the big picture, see how everything
details connects

Self Management

Self Management is the ability to successfully regulate one's

emotions, thoughts, and behaviors in different situations by
effectively managing stress, controlling impulses, and motivating
oneself. This includes the ability to set and work towards
personal and academic goals.

17. I find ways to manage my emotions and express them in useful ways without harming anyone.
Mark only one oval.

1 2 3 4

Never Always
18. I stay calm and clear-headed under high stress and during a crisis.
Mark only one oval.

1 2 3 4

Never Always

19. I have high personal standards that motivate me to do my best.

Mark only one oval.

1 2 3 4

Never Always

20. I set reasonable and challenging goals for myself.

Mark only one oval.

1 2 3 4

Never Always

21. I accept new challenges and adjust to change.

Mark only one oval.

1 2 3 4

Never Always

22. I am able to adjust my thinking when unexpected or new things happen.

Mark only one oval.

1 2 3 4

Never Always

23. I can deal with many responsibilities without losing focus or energy.
Mark only one oval.

1 2 3 4

Never Always

24. I can balance my school life with my home life.

Mark only one oval.

1 2 3 4

Never Always
25. How do you prefer to live your outer life?
Mark only one oval.

1 2

I prefer to have detailed step-by-step I like to improvise and make things up

instructions as I go

26. Mark only one oval.

1 2

I think rules and deadlines should be I see rules and deadlines as

respected flexible

27. Mark only one oval.

1 2

I make plans, I like to know what I’m I am spontaneous, I enjoy surprises and
getting into new situations

Social Awareness

Social Awareness is the ability to take the perspective of and

empathize with others, including those from diverse backgrounds
and cultures. This includes the ability to understand social and
ethical norms for behavior and to recognize family, school and
community resources and supports.

28. I listen actively and can understand another person's perspective and feelings.
Mark only one oval.

1 2 3 4

Never Always

29. I believe that, in general, people are doing their best, and I expect the best of them.
Mark only one oval.

1 2 3 4

Never Always
30. I appreciate and get along with people of diverse backgrounds and cultures in my school
community.
Mark only one oval.

1 2 3 4

Never Always

31. I have the ability to show empathy towards others.

Mark only one oval.

1 2 3 4

Never Always

Relationship Skills

Relationship Skills is the ability to establish and maintain healthy

and rewarding relationships with diverse individuals and groups.
This includes the ability to communicate clearly, listen well,
cooperate with others, resist inappropriate social pressure,
negotiate conflict constructively, and seek and offer help when
needed.

32. I appear approachable, open and willing to communicate with peers, adults and members of
my family.
Mark only one oval.

1 2 3 4

Never Always

33. I am open and honest with others about my values, beliefs and goals.
Mark only one oval.

1 2 3 4

Never Always

34. I am able to openly admit my mistakes to myself and others.

Mark only one oval.

1 2 3 4

Never Always
35. I try to understand the perspective and experiences of others before I offer suggestions or
advice.
Mark only one oval.

1 2 3 4

Never Always

36. I am comfortable talking about conflict; listening to feelings from others and understanding
their different perspective.
Mark only one oval.

1 2 3 4

Never Always

37. I am able to help my peers who may be in conflict and encourage finding a solution.
Mark only one oval.

1 2 3 4

Never Always

38. I involve a trusted adult or peer in important decision-making to ensure I am making wise
choices.
Mark only one oval.

1 2 3 4

Never Always

39. Are you outwardly or inwardly focused?

Mark only one oval.

1 2

I could be described as talkative, I could be described as reserved,

outgoing private

40. Mark only one oval.

1 2

I like to be in a fast-paced I prefer a slower pace with time for

environment thinking

41. Mark only one oval.

1 2

I enjoy being the center of I would rather observe than be the center of
attention attention
Responsible Decision-Making

Responsible Decision-Making is the ability to make constructive

choices about personal behavior and social interactions based
on ethical standards, safety concerns, and social norms. This
includes realistic evaluation of consequences of various actions,
and a consideration of the well-being of oneself and others.

42. I am able to define the core of the problem, explore possible consequences or outcomes and
consider solutions.
Mark only one oval.

1 2 3 4

Never Always

43. I recognize the need for change, challenge myself and encourage others to do the same.
Mark only one oval.

1 2 3 4

Never Always

44. I involve others to help me find solutions for key problems I may be experiencing.
Mark only one oval.

1 2 3 4

Never Always

45. I find ways to overcome challenging situations, even when it comes to making decisions that
may be different than those of my peers.
Mark only one oval.

1 2 3 4

Never Always

46. I treat other people in the way I would want to be treated.

Mark only one oval.

1 2 3 4

Never Always
47. How do you make decisions?
Mark only one oval.

1 2

I make decisions in an impersonal way, I base my decisions on personal values

using logical reasoning and how my actions affect others

48. Mark only one oval.

1 2

I value justice, fairness I value harmony, forgiveness

49. Mark only one oval.

1 2

I could be described as reasonable, level- I could be described as warm,

headed empathetic

Engagement

Engagement is determined by how attentive and invested

students are in school.

50. How excited are you about going to your classes?

Mark only one oval.

1 2 3 4

Not at all excited Extremely excited

51. How often do you get so focused on activities in your classes that you lose track of time?
Mark only one oval.

1 2 3 4

Never Always

52. In your classes, how eager are you to participate?

Mark only one oval.

1 2 3 4

Never Always
53. When you are not in school, how often do you talk about your ideas from your classes?
Mark only one oval.

1 2 3 4

Never Always

54. Overall, how interested are you in your classes?

Mark only one oval.

1 2 3 4

Not at all interested Extremely interested

School Relationships

School Relationships measure how strong the social connection

is between teachers and students both within and beyond the
school environment.

55. How well do people at your school understand you as a person?

Mark only one oval.

1 2 3 4

Do not understand at all Completely understand

56. How connected do you feel to the adults at your school?

Mark only one oval.

1 2 3 4

Not at all connected Extremely connected

57. How much respect do students in your school show you?

Mark only one oval.

1 2 3 4

No respect at all A tremendous amount of respect

58. How much do you matter to others at this school?

Mark only one oval.

1 2 3 4

Do not matter at all Matter a tremendous amount

59. Overall, how much do you feel like you belong at your school?
Mark only one oval.

1 2 3 4

Do not belong at all Completely belong

60. How many of your teachers are respectful towards you?

Mark only one oval.

1 2 3 4

None of my teachers All of my teachers

61. If you walked into class upset, how many of your teachers would be concerned?
Mark only one oval.

1 2 3 4

None of my teachers All of my teachers

62. If you came back to visit three years from now, how many of your teachers would be excited
to see you?
Mark only one oval.

1 2 3 4

None of my teachers All of my teachers

63. When your teachers ask how are you doing, how many of them are really interested in your
answer?
Mark only one oval.

1 2 3 4

None of my teachers All of my teachers

64. How many of your teachers would you be excited to have again in the future?
Mark only one oval.

1 2 3 4

Not at all interested Extremely interested

65. I have at least 1 non-parental caring adult at school

Mark only one oval.

Yes
No
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