NAME: _______________________________ NAME: GRADE LEVEL: _______________________ GRADE LEVEL: Instruction: Check the choice that best corresponds Instruction: Check the choice that best to your answer. corresponds to your answer. 1. Do you have trouble in going to school 1. Do you have trouble in going to early? school early? ___ Yes ____ No ___ Yes ____ No 2. Were you often late to school? 2. Were you often late to school? ____ Yes ____ No ____ Yes ____ No 3. Do you miss your first period 3. Do you miss your first period lessons/quizzes when you are late? lessons/quizzes when you are late? ____ Yes ____ No ____ Yes ____ No 4. Have you been late to school intentionally? 4. Have you been late to school ____ Yes _____ No intentionally? ____ Yes _____ No *If Yes, Why? ___________________________________ *If Yes, Why? __________________________________ _____________________________ _____________________________ 5. Were you late mostly because of: 5. Were you late mostly because of: ____ Traffic ____ You live far ____ Traffic ____ You slept and woke up late ____ You live far ____ Homework/ Projects ____ You slept and woke up late ____ School starts at 7:15 am ____ Homework/ Projects ____ The Teacher was often late ____ School starts at 7:15 am ____ Peer Influence ____ The Teacher was often late ____ Household activities ____ Peer Influence ____ You work at night ____ Household activities ____ You work at night Other reasons: _________________ Other reasons: _________________ 6. Does being late affect your performance in class? 6. Does being late affect your _____ Yes ______ No performance in class? _____ Yes ______ No *If Yes, How? ____________________________________ *If Yes, How? ___________________________________ _____________________________ _____________________________