Student Survey

For mentor to fill out:

Student Code: MA.F10.

Section 1.
Circle the option that best describes your experience.

1. Have you ever worked together with someone or some group to solve a problem in the community where
you live?
A. Yes, within the last 12 months
B. Yes, but not within the last 12 months
C. No, Never
2. Have you ever volunteered or done any voluntary community service for no pay?
A. Yes, within the last 12 months
B. Yes, but not within the last 12 months
C. No, Never

3. Indicate whether or not you have volunteered with each of the following types of organizations or groups.
Check the appropriate box.

Have you volunteered with a… Yes, I volunteer Yes, I have No, not within
once a month or volunteered within the last 12
more the last 12 months months
A. Religious group?
B. Civic or community organization
involved in health or social service?

C. Organization for youth, children, or

education?
D. Other group: ___________________
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 Section 2.
Now, we’re going to ask you a little bit about how you see yourself in the future. Simply put a checkmark in
one of the five option boxes provided.

4.
Thinking ahead to the future, when you think about Extremely Likely Neither Unlikely Extremely
life after high school, how likely do you think you likely likely nor unlikely
will… unlikely

A. Vote on a regular basis?

B. Do some volunteer work on a regular basis?

C. Be an active member of your community?

D. Work on local issues in your community?

E. Participate in a statewide or national campaign?

F. Contact a newspaper or radio or TV show to

express your opinion on an issue?
G. Sign a petition?

H. Take a leadership role in a campaign for an issue

or a politician?
I. Run for political office?
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 Section 3.
The following questions ask for your opinion. How much do you agree or disagree with the following
statements? Mark your answer by checking the box for one of the five options next to each statement.

5.
Strongly Agree Neither agree Disagree Strongly
agree nor disagree disagree

A. I believe I can make a difference in my

community.
B. By working with others in the community, I
can make things better.
C. Being actively involved in community issues is
my responsibility.
D. Being informed about state and local issues is
an important responsibility for everyone.
E. People like me don’t have any say in what
government does.

Section 4.
Now we’re going to ask you some questions about recent current events and the attention you give to current
events in general. Circle the most appropriate answer.

6. As the ninth anniversary of September 11th approaches, the proposed construction of a ______ near
Ground Zero has been the source of much discussion and controversy?
A. A new McDonald’s
B. A Muslim community center
C. A 1776-foot-tall memorial
D. A new fire station
E. I don’t know

7. Chicago Mayor Richard Daley’s decision to retire has led President Obama’s chief of staff to be tempted
to run. Who is Obama’s chief of staff?
A. Joe Biden
B. Nancy Pelosi
C. Rahm Emanuel
D. Arne Duncan
E. I don’t know
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 8. ________, coupled with the recession, decreased travel and tourism revenues on the East Coast over
Labor Day weekend.
A. Unseasonably cold temperatures
B. Major highway construction with federal stimulus money causing traffic jams
C. A focus on upcoming midterm elections
D. A hurricane/tropical storm
E. I don’t know

9. To what extent do you agree with the following statements?

I know a lot about… Strongly Disagree Neither disagree Agree Strongly

disagree nor agree agree

A. Local issues and news

B. National issues and news

C. Global issues and news

10. On average, how much time do you spend each week following current events? (i.e. reading the
newspaper, watching a television news program, reading articles online, talking with family and friends
about current topics, etc.)
A. None
B. 15 minutes or less per week (i.e., less than 2 minutes per day)
C. More than 15 minutes and up to 1 hour per week (i.e., up to 9 minutes per day)
D. More than 1 hour and up to 4 hours per week (i.e., up to 30 minutes per day)
E. More than 4 hours per week (i.e., more than 30 minutes per day)

Section 5.
The following two questions pertain to the current US political system. Circle the best answer.

11. Which party has the most members in the House of Representatives in Washington?
A. Democrats
B. Republicans
C. Independents
D. Democrats and Republicans have the same amount
E. I don’t know

12. What position does Joe Biden hold?

A. Secretary of State
B. Vice President
C. Chief Justice of the Supreme Court
D. House Majority Leader
E. I don’t know
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 The following questions deal with the US government and its structure. Circle the best answer.

13. Whose responsibility is it to determine if a law is constitutional or not?

A. President
B. Congress
C. Supreme Court
D. City Council
E. I don’t know

14. What are both citizens and noncitizens legally entitled to in the United States?

A. The ability to run for public office

B. A United States passport
C. The protection of our laws
D. The ability to vote in primary elections
E. I don’t know

15. What are the three branches of the federal (national) government of the United States?

A. Republican, Democrat, and Independent

B. Legislative, executive, and judicial
C. Local, state, and federal
D. State, national, and international
E. I don’t know

The following section asks specifically with democracies and democratic practices.

16. A fourth-grade class was given the opportunity to prepare its own lunch. Which of the following would be
the most democratic way for the class to decide on the menu?
A. The teacher decides which foods to serve.
B. The students make a list of their favorite foods and vote on what to serve.
C. The students with the best grades choose which foods to serve.
D. The teacher makes a list of his/her favorite foods and allows the students to vote on what to serve.
E. I don’t know

17. In democracies, citizens elect people to make laws for them because
A. that way, they know who the most popular people are
B. that way, the most popular people are the ones who get to make the laws
C. most people already agree about what laws they should have
D. it is easier than having everyone vote on every decision
E. I don’t know
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 18. The cartoon below came from a newspaper. What is its message? (The word apathy in the cartoon
means “not caring”).

A. Democracy could be in danger if people do not vote.

B. People like to get all their political ideas from television.
C. People do not care whether they have the right to freedom of speech.
D. It is difficult to be a candidate for President.
E. I don’t know

The next three questions are about your state’s political representatives.

19. Who are the two US Senators representing Massachusetts?

1.______________________________ 2.________________________________

20. Who is the Governor of Massachusetts?

___________________________________________

21. Who is the Mayor of Boston?

___________________________________________
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 Section 6.
For the questions in this table, suppose you are frustrated by the lack of after-school opportunities available
in your community and you want to do something about it. Examining your own abilities, what do you think
you would be able to do? For each row, check the appropriate response.

22. Would you be able to…

Would you be able to… Yes Probably yes Maybe Probably not No
A. Create an action plan to address
the issue?
B. Get people to care about the
issue?
C. Organize and run a meeting
about the issue?
D. Make a public speech on the
issue?
E. Find and examine research
related to the issue?
F. Write an opinion letter to your
local newspaper on the issue?
G. Organize a petition on the issue?

23. Which of the following tasks have you done before? Circle all that apply.
A. created an action plan to address an issue
B. gotten people to care about an issue
C. organized and ran a meeting about an issue
D. made a public speech about an issue
E. found and examined research related to an issue
F. written an opinion letter to my local newspaper about an issue
G. organized a petition on an issue
H. other: ___________________________________
I. none of the above

Section 7.
The next few questions pertain to your academic performance in school.

24. On your report card last semester, what sort of grades did you get?
A. Mostly As
B. Mostly Bs
C. Mostly Cs
D. Mostly Ds
E. I’d rather not say
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25. Are you currently taking any honors, Advanced Placement (AP), or college classes? (circle one)
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Yes No
 26. If you are taking any honors, AP, or college classes, please list them here:

___________________________________________

27. How often do you participate in a typical academic class? (i.e. volunteering to answer a question,
contributing to class discussion, etc.)
A. Two or more times per class
B. Once per class
C. A few times each week
D. A few times each month
E. I don’t usually speak in class

28. What is the highest level of education you plan on attaining?

A. Some high school classes
B. High school degree
C. Some college classes
D. Two-year college degree
E. Four-year college degree
F. Graduate degree

29. How many days last semester were you absent from school without an excuse from your
parent/guardian or teacher? (this does not include absences if you were sick or for religious holidays,
etc.)
A. 0
B. 1-5
C. 6-10
D. more than 10
E. I don't know

Finally, please tell us a little bit more about yourself.

30. What is your gender? Please circle one of the options below.
Male Female
31. What is your race/ethnicity? Please circle all that apply.
African American and/or black
Asian and/or Pacific Islander
Caucasian and/or white
Hispanic and/or Latino
Other (please specify: _________________________________________)

32. Are you religious? Please circle one of the options below.
Yes No
33. If you identify as religious, please note your religious affiliation below (i.e. Jewish, Roman Catholic,
Muslim, etc.):
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___________________________________________