Youth Survey

Amachi Pittsburgh Youth Survey
There are no right or wrong answers. We just ask that you answer the questions as truthfully and completely as possible. If you do not want to answer a question, you can leave it blank. However, all of your answers will be kept private. They will not be shared with your parent/guardian, teacher, or mentor, and they will not be used to decide whether you get a mentor. If you do not understand the meaning of a question, you can ask an Amachi Pittsburgh staff person to help you.
Parent/Guardian Name*
First Last
Youth/Mentee Name*
First Last
Date Completed*
Amachi Staff Name
First Last
if staff person assists with survey completion
Youth Gender
Youth Race/Ethnicity
School
Please think about the grades and marks that you are getting in school. We would like to know how you are doing in each of the following subjects. For each subject area, please choose the response for Not Good at All (F), Not so Good (D), Good (C), Very Good (B), and Excellent (A).
Grades in Mathematics
Grades in Reading or Language Arts
Grades in Social Studies
Grades in Science
Think about your school attendance in the past 30 days. Choose the response that corresponds to how often you have done each of these things. If it is the summer, think about the last thirty days that you were in school.
How often, in the past 30 days, have you had an excused absence from school?
How often, in the past 30 days, have you had an unexcused absence from school?
How often, in the past 30 days, have you skipped school without permission?
How often, in the past 12 months, have you been suspended from school?
Emotional Well Being
For each item below, please choose the response that corresponds most to how you felt over the last month.
Over the last month, I had many worries or was often worried.
Over the last month, I was often unhappy, depressed, or tearful.
Over the last month, I had many fears and was easily scared.
Self-Confidence
These questions ask about how you feel about yourself and other youth. For each item below, please mark the box that best corresponds to how you feel.
I am always doing things with a lot of kids.
I wish that more people my age liked me.
I find it hard to make friends.
I would like to have a lot more friends.
I am popular with others my age.
I have a lot of friends.
Personal Behaviors & Activities
These next questions ask about some behaviors and activities that you might have done in the past 30 days or 12 months. Choose the response that corresponds to how often you have done each.
How often, in the past 30 days, have you used tobacco or alcohol?
How often, in the past 30 days, have you used marijuana or other drugs, not including medicine?
How often, in the past 12 months, have you been arrested for a crime, offense, and/or a violation?
How often, in the past 12 months, have you been initiated into a named gang?
How often, in the past 30 days, have you engaged in delinquency (stealing, vandalism, gangs, weapons)?
How often, in the past 30 days, have you engaged in religion (spiritual interest)?
How often, in the past 30 days, have you engaged in extracurricular activities (e.g. athletics, performing arts, etc.)?
How often, in the past 30 days, have you engaged in sexual activity?
Social Behavior
For each item below, please choose the response that corresponds to how you felt over the last month.
Over the last month, I was easily distracted or had trouble focusing.
Over the last month, I had a good attention span, and finished what I started.
Over the last month, I was restless and could not sit still for long.
Over the last month, I was generally well-behaved and usually did what adults asked me to do.
Over the last month, I often lost my temper.
Over the last month, I often lied and cheated.
Over the last month, I got along better with adults than with other youth.
Over the last month, I thought about other people's feelings.
Over the last month, I shared with other youth (e.g. CDs, games, and food).
Over the last month, I was kind to younger children.
Over the last month, I interacted well with strangers.
Over the last month, I reacted appropriately to discipline.
Over the last month, I thought things out before acting.
Over the last month, I stole from home, school, or elsewhere.
Over the last month, I often fought with other youth.
Over the last month, I often bullied other youth.
Over the last month, I was picked on or bullied by other youth.
Family Relationship
Listed below are statements about families. Please read each statement and indicate your level of agreement to the statement. For each item below, please choose the response for Strongly Disagree, Disagree, Neither Agree nor Disagree, Agree, or Strongly Agree.
Facing Challenges: To what extent is each of the following statements like your family?
No matter how difficult things get, our family sticks together.
When we have a problem or concern, we are able to make decisions about what to do.
If something is beyond our control and is constantly upsetting to our family, we find things to do that keep our minds off our worries.
We generally ask for help from people outside our family if we cannot do things ourselves.
In our family, we can depend upon the support of one another whenever something goes wrong.
We try to solve our problems before asking others to help.
Communication: To what extent is each of the following statements like your family?
We generally agree about how family members are expected to behave.
We are able to share our concerns and feelings in productive ways.
Whenever we have disagreements, family members listen to "both sides of the story."
We can express feelings to each other.
We are reluctant to show our affection for each other.
In our family, we try not to take one another for granted.
Celebrating Our Family: To what extent is each of the following statements like your family?
We take pride in the smallest accomplishments of family members.
Even in our busy schedules, we find time to be together.
In our family, our relationships will outlast our material possessions.
Our family has traditions that we do annually to celebrate birthdays, holidays, and/or anniversaries.
Our family eats dinner together as a family on a regular basis.
We enjoy time together even if it is just doing household chores.
Special Adult
Please answer the following question(s) about a special adult in your life. A special adult is someone who does a lot of good things for you and who is not a parent or guardian. For example, someone (a) who you look up to and encourages you to do your best, (b) who really cares about what happens to you, (c) who influences what you do and the choices you make, and (d) who you can talk to about personal problems, could be considered a special adult.
Right now in my life, I have a special adult who I often spend time with.
If you answered "yes," who is this special adult?
Check all that apply. To select multiple options, click and hold Control. A 'non-Amachi' mentor is a mentor that you are matched with through a different organization or program.
Other:
Mentor/Mentee Relationship
Every mentor/mentee relationship is unique, so each has a different approach. Please help us understand your mentee/mentor relationship by choosing a number from the scale-never important (1) to always important (6). How important do you consider the following focus areas in your mentoring relationship?
In our relationship, my mentor and I focus on helping with schoolwork/academics.
In our relationship, my mentor and I focus on talking about problems with friends/peers.
In our relationship, my mentor and I focus on sharing life experiences.
In our relationship, my mentor and I focus on talking about careers.
In our relationship, my mentor and I focus on talking about future education (high school and/or college).
In our relationship, my mentor and I focus on making time to goof around, laugh, and have light-hearted fun.
How do you feel about your match?
Please choose the response that corresponds to how much you agree or disagree with the following statements. The scale is from completely disagree (1) to completely agree (6).
I think my mentor and I are a good match for each other.
I feel like my mentor is making a difference in my life.
I am so busy that it is difficult for me to see my mentor regularly.
The distance I have to travel to see my mentor is a problem for me.
Amachi provides special events and activities that my child enjoys going to with his/her mentor.
Overall Reflections
What could Amachi Pittsburgh have done to make the program better so far?
Tell us about your interaction/relationship with the Amachi Pittsburgh staff.
If you feel like your mentor has "made a difference" in your life, can you please write an example of how?
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Youth Survey

Youth Survey

Amachi Pittsburgh Youth Survey

School

Emotional Well Being

Self-Confidence

Personal Behaviors & Activities

Social Behavior

Family Relationship

Facing Challenges: To what extent is each of the following statements like your family?

Communication: To what extent is each of the following statements like your family?

Celebrating Our Family: To what extent is each of the following statements like your family?

Special Adult

Mentor/Mentee Relationship

How do you feel about your match?

Overall Reflections