Student Needs Survey A universal screening and outcomes assessment instrument for the Upstream Project to prevent youth homelessness and school dropout in U.S. communities Version: Hopkins Public Schools 2019 Updated: November 14, 2019 PLEASE READ: Chapin Hall at the University of Chicago shares this instrument upon request as a reference for informational purposes only. Please do not modify or use this instrument without written permission from Dr. Matthew Morton (mmorton@chapinhall.org), Dr. Melissa Kull (mkull@chapinhall.org), or Ms. Beth Horwitz (bhorwitz@chapinhall.org) at Chapin Hall at the University of Chicago. Several measures included in this instrument are based on validated, proprietary scales. Modifications to those measures could both compromise their validity and undercut intellectual property. In each community in which Chapin Hall partners with schools and service providers to implement and evaluate the Upstream Project, Chapin Hall researchers work with local stakeholders to make adaptations to this instrument so that it is customized to local needs and context. Researchers then pilot the instrument with students locally. As such, this instrument is not “fixed.” It is subject to change for each Upstream community and from one year to the next. If your school system or community is interested in implementing the Upstream Project and administering a version of this instrument, please contact Dr. Morton, Dr. Kull, or Ms. Horwitz. Note: This instrument is typically administered in schools via an online survey that students complete directly using REDcap, the University of Chicago’s secure technology-based data collection platform, on school-owned computers or tablets. The online survey provides both audio recording and visual text of the contents. We are working on professional translations as required by some pilot school districts. The source of each measure is indicated as “[XX]” in this version of the survey. Student Needs Survey: Hopkins Public Schools On any given night, more than 6,000 youth in Minnesota don’t have a stable place to live and 17% of Minnesota’s high school seniors did not graduate last year. Hopkins Public Schools (HPS) wants to provide more resources and supports to its students and their families. Please complete the survey to help HPS understand what resources and supports its students and their families need. Please read the following information and then decide if you agree to participate in the survey. Introduction. Hopkins Public Schools (HPS) has asked Chapin Hall at the University of Chicago, a nonprofit research center, to study its new program, the Upstream Project. The purpose of the Upstream Project is to identify students at risk for homelessness and school dropout and to connect them to a local youth service provider called MoveFwd. Study Procedures. As part of the project, all 7th through 12th graders in HSP are being asked to complete the Students Needs Survey (SNS) on a computer or tablet during school hours. The SNS asks questions about your life inside and outside of school. Some questions on the survey might seem a little personal, but please answer them honestly so HPS can better understand what is going well for students, where students might be facing difficulties. The results will help HPS figure out what resources and supports students and their families need. Risks. The survey asks some sensitive questions so there is a small chance that you will experience some discomfort when you complete the survey. If you are feeling distressed, you can reach out to the resources listed on the form that your teacher distributed and listed on the screen at the end of the survey. Benefits. The survey results will be used to help provide more resources and supports to Hopkins Public Schools students and their families in the future and may help connect you and your family to services. Use of Your Data. Chapin Hall will use the survey data to identify students who are at risk for homelessness or school dropout. Because the survey will ask for your student ID number but not your name, Chapin Hall will provide school staff with a list of ID numbers for the students who are at risk. If your ID number is on that list, school support staff might reach out to you to share information about services for you and your family. It will be up to you and your family to decide if you want those services. Data Confidentiality. Only the Chapin Hall researchers will know how you answer the survey questions. Your responses to the survey questions will not be shared with your school, parents, guardians, or anyone else. However, Chapin Hall is required to notify the appropriate authorities if you report that you are being harmed or that you are going to harm yourself or someone else. Right to Refuse or Withdraw. Participation in this study is voluntary. Nothing will happen to you if you choose not to complete the survey. You can also choose not to answer all of the survey questions. Chapin Hall may ask you to participate in other parts of this study in the future. You can decide later if you want to participate in those other parts of the study. Right to Ask Questions and Report Concerns. If you decide to opt out after starting, you can tell Mr. Brian Stanley, the Hopkins Public Schools Supervisor of Special Services, at (952)988-4319. If you have any questions about your involvement in this this research, you can ask your school counselor, other school support staff, or Dr. Matthew Morton who is leading the Chapin Hall study of Upstream. He can be contacted at mmorton@chapinhall.org or 202-412-6105. If you have any questions about your rights as a study participant, you can contact the University of Chicago’s Institutional Review Board (IRB) at SSAIRB@uchicago.edu or (773) 834-0402. Student ID Number: ___________________________ Name of School: ________________________________________ Grade: __________________ If your survey responses indicate that you are at risk for homelessness or school dropout, someone from your school might reach out to talk with you about services for you or your family. Who would you like to learn about those services from? __ Guidance counselor [names dropdown] __ School social worker [names dropdown] __ School psychologist [names dropdown] __ School nurse [names dropdown] __ Other [specify: _____________________ ] As you complete the survey, you will notice that the response options are different for different questions. Be aware of this and read each question carefully! 3 Please describe yourself. 1. How old are you? _______ 12-21 2. How would you describe your race and ethnicity? Select all that apply. [YRBS] 1 2 3 4 5 6 7 97 98 White Black Hispanic or Latino Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Other [Please specify] DK REF 3. What sex were you assigned at birth, that is, what sex is listed on your original birth certificate? [Williams Institute] 1 2 97 98 Female Male DK REF 4. How would you describe your gender? Select the best answer for you. [Williams Institute] 1 2 3 4 97 98 Female Male Transgender Do not identify as female, male, or transgender DK REF 5. Which of the following best describes your sexual orientation? [YRBS] 1 2 3 4 97 98 Gay or Lesbian Bisexual Heterosexual (straight) Other DK REF 4 6. Are you or your partner pregnant? [CH] 1 2 97 98 Yes No DK REF 7. Are you a parent? [CH] 1 2 97 98 Yes No DK REF The first set of questions asks about your current living arrangement. 8. During the past 30 days, where did you usually sleep? [YRBS] 1 2 3 4 5 6 7 97 98 In my parent's or guardian's home In the home of a friend, family member, or other person because I had to leave my home or my parent or guardian cannot afford housing In a shelter or emergency housing In a motel or hotel In a car, park, campground, or other public place I do not have a usual place to sleep Somewhere else DK REF 9. During the past 30 days, did you ever sleep away from your parents or guardians because you were kicked out, ran away, or were abandoned? [YRBS] 1 2 97 98 Yes No DK REF Indicate what you think is the best answer to describe your home life – on a scale from strongly disagree to strongly agree. [AUS] 10. I feel safe in the place where I live now. 11. I would like to move out of the place where I am living. 12. There is a lot of conflict in the place where I am living. Strongly disagree 1 [1] Disagree 2 [2] Neutral 3 [3] Agree 4 [4] Strongly agree 5 [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] 5 The next set of questions asks you to think about your experiences in the past year. In other words, since [CURRENT MONTH, CURRENT YEAR MINUS ONE]. 13. Which of the following (if any) have been present where you have lived at any time for the past year? Check all that apply. [HUD’s American Housing Survey) 1 2 3 4 5 6 7 8 9 10 97 98 No hot or cold running water No bathtub or shower No working toilet No electricity Cold/no heat in winter Electrical wires exposed (coming out of wall, for example) Holes in the floor Rats/rodents Peeling paint the size of a notebook NONE DK REF 14. In the last year, how often did you/your family worry that food would run out? [material hardship scale] 1 2 3 4 97 98 Very often Somewhat often Not very much Not at all DK REF 15. In the last year, how often have you (or your family) experienced having phone, electricity, or other utilities cut off because the bill(s) were unpaid? [material hardship scale] 1 2 3 97 98 Never 1-2 times 3 or more times DK REF 16. How many times have you moved from one address to another during the past year? [YV Lifeset] _______ 0-50 17. Was there a time in the past year when you or your family could not pay the rent or mortgage because you did not have enough money? [YV Lifeset] 1 Yes 6 2 97 98 No DK REF 18. In the past year, was there a time when you or your family were evicted from your apartment, lost your home, or were asked to leave where you were living because you did not have enough money to pay the rent or mortgage? [adapted from YV Lifeset] 1 2 97 98 Yes No DK REF 19. During the past year, how many times have you and your family stayed with friends or relatives because you did not have a place to stay? [CH] ____ 0-50 20. During the past year, how many different times have you found yourself homeless for one or more nights? By homeless I mean that you have slept in a homeless shelter or in a place where people weren't meant to sleep because you didn't have a place to stay. [YV Lifeset] ____ 0-50 21. During the past year, how many different times have you found yourself couch surfing for one or more nights? By couch surfing, I mean staying temporarily with your friends, family, or strangers because you didn’t have a permanent place to stay. [YV Lifeset] ____ 0-50 22. Are you worried that you might run away or be asked to leave home sometime this year? [CH] 1 2 97 98 Yes No DK REF 23. Are you worried that you or your family might not have a stable or safe place to stay sometime this year? [CH] 1 2 97 98 Yes No DK REF 24. Have you ever experienced the death of a parent or guardian? [CH] 7 1 2 97 98 Yes No DK REF 25. Have you ever experienced a parent or guardian permanently leaving your life because of separation or divorce? [CH] 1 2 97 98 Yes No DK REF 26. Have you ever experienced a parent or guardian going to prison or jail? [CH] 1 2 97 98 Yes No DK REF 27. Have you ever been in foster care? [CH] 1 2 97 98 Yes No DK REF 28. Have you ever been arrested? [CH] 1 2 97 98 Yes No DK REF [IF Q24=1 THEN GO TO Q24B] 28B. Have you ever been in prison, jail, or juvenile detention? [CH] 1 2 97 98 Yes No DK REF The next set of questions is about your current and recent experiences at school. 29. Compared to other students in your school, what kind of student would you say you are? [YRBS] 8 1 2 3 4 5 6 97 98 One of the best Far above the middle A little above the middle In the middle A little below the middle Far below the middle DK REF 30. During the past year, how many times have you changed schools? [CH] ____ 0-50 31. During the past year, how often were you bullied, picked on, or excluded by other students? [adapted from NCHS] 1 2 3 4 5 97 98 Never (in past 12 months) 1-2 times (in past 12 months) 1-2 times per month 1-2 times per week Almost every day DK REF 32. During the past year, how many days of school have you missed? Please estimate. [adapted from NSCH] ____ 0-200 33. Have you ever been held back or repeated a grade? [CH] 1 2 97 98 Yes No DK REF 34. Have you ever been suspended from school? [CH] 1 2 97 98 Yes No DK REF 35. Have you ever been expelled from school? [CH] 1 2 97 Yes No DK 9 98 REF 36. Are you worried that you might stop going to school sometime this year? [CH] 1 3 97 98 Yes No DK REF Indicate what you think is the best answer to describe your school life – on a scale from strongly disagree to strongly agree. [AUS] 37. I enjoy going to school every day. 38. If I were able to get a job, I would leave school now. 39. I regularly skip school (in other words, miss school without permission). 40. I get along well with most of my teachers. 41. I get into a lot of trouble at school. Strongly Strongly disagree Disagree Neutral Agree agree 1 2 3 4 5 [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] The following statements are about you [Youth Thrive Resilience Scale]. Please use the answer choices to tell us how much each statement is—or is not—like you. The answer choices are not at all like me, a little like me, sort of like me, a lot like me, or very much like me. 42. I learn from my mistakes. 43. I believe I will be okay even when bad things happen. 44. I do a good job of handling problems in my life. 45. I try new things even if they are hard. 46. When I have a problem, I come up with ways to solve it. 47. I give up when things get hard. 48. I deal with my problems in a positive way (like asking for help). 49. I keep trying to solve problems even when things don’t go my way. 50. Failure just makes me try harder. Not at all like me A little like me Sort of like me A lot like me Very much like me 1 [1] 2 [2] 3 [3] 4 [4] 5 [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] 10 51. No matter how bad things get, I know the future will be better. [1] [2] [3] [4] [5] The following statements are about how you relate to with your teacher, your friends, your parent(s) or guardian(s), and how you get by at school. Please use the answer choices to tell us how much each statement is—or is not—like you. The answer choices are not at all like me, a little like me, sort of like me, a lot like me, or very much like me. [Youth Thrive measure of social connectedness] 52. There are people in my life who encourage me to do my best. 53. I have someone who I can share my feelings and ideas with. 54. I have someone in my life who I look up to. 55. I have someone in my life who doesn’t judge me. 56. I feel lonely. 57. I have someone I can count on for help when I need it. 58. I have someone who supports me in developing my interests and strengths. 59. I have a friend or family member to spend time with on holidays and special occasions. 60. I know for sure that someone really cares about me. Not at all like me 1 A little like me 2 Sort of like me 3 A lot like me 4 Very much like me 5 [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] The following statements are about how you relate to with your teacher, your friends, your parent(s) or guardian(s), and how you get by at school. Please use the answer choices to tell us how much each statement is—or is not—like you. The answer choices are not at all like me, a little like me, sort of like me, a lot like me, or very much like me. [Youth Thrive measure of social connectedness] 61. I have someone in my life who is proud of me. 62. There is an adult family member who is there for me when I need them (for example, my birth or adoptive parent, spouse, adult sibling, extended family member, legal guardian, nonbiological chosen family). 63. There is an adult, other than a family member, who is there for me when I need them. Not at all like me 1 [1] [2] Sort of like me 3 [3] A lot like me 4 [4] Very much like me 5 [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] A little like me 2 11 64. I have friends who stand by me during hard times. 65. I feel that no one loves me. 66. My spiritual or religious beliefs give me hope when bad things happen. 67. I try to help other people when I can. 68. I do things to make the world a better place like volunteering, recycling, or community service. [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] [1] [2] [3] [4] [5] The following questions ask about how you have been feeling during the past 30 days. [K6] For each question, please circle the number that best describes how often you had this feeling - on a scale from all of the time to none of the time. During the past 30 days, about how often did you feel… 69. 70. 71. 72. … nervous? … hopeless? … restless or fidgety? … so depressed that nothing could cheer you up? 73. … that everything was an effort? 74. … worthless? None of the time Some of the time 2 [2] [2] [2] Most of the time All of the time 0 [0] [0] [0] A little of the time 1 [1] [1] [1] 3 [3] [3] [3] 4 [4] [4] [4] [0] [1] [2] [3] [4] [0] [0] [1] [1] [2] [2] [3] [3] [4] [4] 12