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HomeMy WebLinkAboutBBBS Additional Attachment© Big Brothers Big Sisters of America, 2019. Unauthorized use, distribution, transmission, and/or duplication of this material without express and written permission from Big Brothers Big Sisters of America is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Big Brothers Big Sisters of America with appropriate and specific direction to the original content. (Revised August 2020) CHILD OUTCOMES SURVEY It is very important for Big Brothers Big Sisters (BBBS) to learn about the youth who participate in its programs and what things are like for them. You can help by completing this survey. • This survey asks about how things are going in school, at home, and in your life. • There are no right or wrong answers. Please answer the questions as honestly as possible. • If you don’t want to answer a question, you can leave it blank. • No one except BBBS staff will ever see your exact answers on this survey without your permission. However, the last two sections ask about your feelings and behaviors. Depending on your answers in these sections, we may want to ask you more questions and may want to share any concerns with your parent(s) or guardian(s) or a professional who can help. We will let you know when those sections begin. • Your answers will not have any effect on being in the BBBS program or how you are treated in it. The survey is voluntary. • We will start by reading it out loud to everyone. After we get through a few questions, if you feel like you’d rather complete the rest on your own, just let me know. • The choices you have for how to answer these questions change in different parts of the survey, so please read each choice carefully! Thank you for your help! Please let a BBBS staff member know if you have any questions. FOR AGENCY USE ONLY Participant ID: Date Survey Completed by Child: 2 VERY IMPORTANT ADULTS Sometimes people your age have an adult in their life who is ALL of these things:  Someone they’ve known for a while;  Someone they often spend time with;  Someone they can really count on when they need help; and  Someone who cares a lot about what happens to them. Put an X in the box that fits best No Yes a. Is there an adult who you live with (for example, a parent or someone else who takes care of you) who is ALL of these things for you?   b. Is your Big (this includes high school Bigs) through this program ALL of these things for you? [If you have never met your Big, please check “No”]   YOUR LIFE These questions ask about how you feel about yourself and school. Decide how true each sentence is for you and put an X in the box that fits best. Put an X in the box that fits best Not at all true A little true Mostly true Totally true a. I can relax when I feel tense.     b. I work hard at school.     c. I get bored in school a lot.     d. I can keep my feelings from getting out of control.     e. I do well in school.     f. I can make myself feel better when I am worried.     g. I enjoy being at school.     h. I feel good about myself when I am at school.     i. I can control myself when I get angry.     j. Doing well in school is important to me.     THINGS YOU HAVE DONE IN THE PAST MONTH Kids get in trouble for a lot of things. The next questions ask about things you got in trouble for or things you did that you could have gotten in trouble for in the past month. In the past month, I got in trouble for or could have gotten in trouble for: 0 times 1 or 2 times 3 or more times a. Teasing other kids.    b. Saying mean things about kids to make other kids laugh.    c. Pushing, shoving, slapping, hitting, or kicking other kids.    d. Calling other kids names.    e. Threatening to hit or hurt another kid.    3 Your answers in the rest of the survey may require us to ask more questions and we may want to share this information with your parent(s)/guardian(s) or a professional who can help. Remember, you can skip a question if you are not comfortable answering. THINGS YOU HAVE DONE IN THE PAST 3 MONTHS OF SCHOOL These next questions ask about things that may have happened to you in the past 3 months of school. If it is summer, think about the last 3 months of school. Remind yourself how long ago the last three months of school was by writing something that happened in your life close to that time: Put an X in the box that fits best In the past 3 months of school, I: 0 times 1 or 2 times 3 or more times a. Had to have a parent or guardian come to school about a problem with my behavior.    b. Had to see the principal or other staff person at school because of an issue with my behavior (but didn’t get a suspension or detention for it).    c. Got sent to detention (either during school, afterschool, or on a weekend) because I got in trouble.    d. Got suspended (I was not allowed to come to school for one or more days) because I got in trouble.    YOUR MOODS AND FEELINGS These last questions ask about how you might have felt recently. For each sentence, think about how often you have felt this way in the past week. Put an X in the box that fits best In the past week: Never Almost Never Sometimes Often Almost Always a. I could not stop feeling sad.      b. I felt alone.      c. I felt everything in my life went wrong.      d. I felt happy.      e. I felt like I couldn’t do anything right.      f. I felt lonely.      g. I felt sad.      h. I felt unhappy.      i. It was hard for me to have fun.      j. I felt proud.      THANK YOU! TO BE COMPLETED BY MENTOR Mentor’s Name: _______________________________________ Mentor’s Date of Birth: Check one: Ethnicity: Check if: Male 0 Female 1  American Indian  Asian  Black  Hispanic High School Student 0  Multi-Race  Multi-Race (Black and Asian) College Student 1  Multi-Race (Black and Hispanic)  Multi-Race (White and Asian)  Multi-Race (White and Black)  Multi-Race (White and Hispanic)  Native Hawaiian or Pacific Islander  White  Other Today’s Date: To what extent do you agree with the following statements? (Circle One) Strongly Disagree Disagree Neutral Agree Strongly Agree I Don’t Know 1. I am enjoying the experience of being a Big. 1 2 3 4 5 DK 2. I expected that being a mentor would be more fun than actually it is. 1 2 3 4 5 DK 3. My Little and I are interested in the same things. 1 2 3 4 5 DK 4. I feel confident handling the challenges of being a mentor. 1 2 3 4 5 DK 5. Being a Big is more of a time commitment than I anticipated. 1 2 3 4 5 DK 6. I feel overwhelmed by my Little’s family difficulties. 1 2 3 4 5 DK 7. My Little has made improvements since we started meeting. 1 2 3 4 5 DK 8. I sometimes feel frustrated with how few things have changed with my Little. 1 2 3 4 5 DK 9. My Little and I are sometimes at a loss for things to talk about. 1 2 3 4 5 DK 10. It is hard for me to find the time to be with my Little. 1 2 3 4 5 DK 11. I think my Little and I are well-matched. 1 2 3 4 5 DK 12. I get the sense that my Little would rather be doing something else. 1 2 3 4 5 DK 13. My Little has trouble sticking with one activity for very long. 1 2 3 4 5 DK 14. I feel close to my Little. 1 2 3 4 5 DK 15. Which of the following best describes how decisions are usually made about how you and your Little will spend your time together? [Please check only one box.] 1 I usually decide how we’ll spend our time together. 2 My Little usually decides how we’ll spend our time together. 3 I get ideas from my Little then we decide together. 4 The agency case manager outlines how we will spend our time together. 5 Someone else (like a teacher or parent) decides how we’ll spend our time together. FOR AGENCY USE ONLY CB 1 SB 2 Other 3 Date of Match: 3 month SoR 0 12 month or EOSY SoR 1 MENTOR STRENGTH OF RELATIONSHIP SURVEY © Big Brothers Big Sisters of America, 2019. Unauthorized use, distribution, transmission, and/or duplication of this material without express and written permission from Big Brothers Big Sisters of America is strictly prohibited. Excerpts and links may be used, provided that full and clear credit is given to Big Brothers Big Sisters of America with appropriate and specific direction to the original content. (Revised August 2020) YOUTH OUTCOMES SURVEY It is very important for Big Brothers Big Sisters (BBBS) to learn about the youth who participate in its programs and what things are like for them. You can help by completing this survey. • This survey asks about how things are going in school, at home, and in your life. • There are no right or wrong answers. Please answer the questions as honestly as possible. • If you don’t want to answer a question, you can leave it blank. • No one except BBBS staff will ever see your exact answers on this survey without your permission. However, the last two sections ask about your feelings and behaviors. Depending on your answers in these sections, we may want to ask you more questions and may want to share any concerns with your parent(s) or guardian(s) or a professional who can help. We will let you know when those sections begin. • Your answers will not have any effect on being in the BBBS program or how you are treated in it. The survey is voluntary. • We will start by reading it out loud to everyone. After we get through a few questions, if you’d rather complete the rest on your own, just let me know. • The choices you have for how to answer these questions change in different parts of the survey, so please read each choice carefully! Thank you for your help! Please let a BBBS staff member know if you have any questions. FOR AGENCY USE ONLY Participant ID: Date Survey Completed by Youth: 2 SCHOOL Think about the grades you got on your last report card. Which of the choices below best describes these grades? If you get different kinds of marks like 0 to 100 or other kinds of grades, please choose the answer that comes closest to those marks or grades. If you don’t get a mark or grade for a subject, just check the last box to show this. Put an X in the box that fits best F (Not Good at All) D (Not So Good) C (Okay) B (Good) A (Excellent) I didn’t get a grade for this subject. a. Math       b. English or Language Arts       c. Social Studies or History       d. Science       YOUR PLANS FOR THE FUTURE These questions ask about your plans for the future. Remember, there are no right or wrong answers – just answer as honestly as possible. Put an X in the box that fits best No Not Sure Yes a. Do you think you will finish high school?    b. Do you plan on going to college at some point?    What do you think you will do in your first year after high school? Check all that apply.  I don’t know yet.  Get a job  Go to a university or four-year college  Go to a community college or technical school (such as a school to become a medical assistant, construction worker, hair/makeup artist, or mechanic)  Join the military  Something else (Please describe: ) VERY IMPORTANT ADULTS Sometimes people your age have an adult in their life who is ALL of these things:  Someone they’ve known for a while;  Someone they often spend time with;  Someone they can really count on when they need help; and  Someone who cares a lot about what happens to them. Put an X in the box that fits best No Yes a. Is there an adult who you live with (for example, a parent or someone else who takes care of you) who is ALL of these things for you?   b. Is your Big (this includes high school Bigs) through this program ALL of these things for you? [If you have never met your Big, please check “No”]   3 YOUR LIFE These questions ask about how you feel about yourself, other kids, school, and your family. For the questions about your family, think about your parent(s) or other adults who are most responsible for taking care of you. Put an X in the box that fits best Not at all true A little true Mostly true Totally true a. I work well with other kids at school.     b. I get along with my parents.     c. I can relax when I feel tense.     d. I work hard at school.     e. I like spending time with my parents.     f. I get bored in school a lot.     g. I am good at talking to kids I don’t know.     h. I can keep my feelings from getting out of control.     i. I can make friends with other kids.     j. I want my parents to be proud of me.     k. I can tell other kids to stop when they are doing something I don’t like.     l. I do well in school.     m. I can make myself feel better when I am worried.     n. I enjoy being at school.     o. I can stay friends with other kids.     p. I feel good about myself when I am at school.     q. I can control myself when I get angry.     r. Doing well in school is important to me.     THINGS YOU HAV E DONE IN THE PAST MONTH Kids get in trouble for a lot of things. The next questions ask about things you got in trouble for or things you did that you could have gotten in trouble for in the past month. Put an X in the box that fits best In the past month, I got in trouble for or could have gotten in trouble for: 0 times 1 or 2 times 3 or more times a. Teasing other kids.    b. Saying mean things about kids to make other kids laugh.    c. Pushing, shoving, slapping, hitting, or kicking other kids.    d. Calling other kids names.    e. Threatening to hit or hurt another kid.    4 Your answers in the rest of the survey may require us to ask more questions and we may want to share this information with your parent(s)/guardian(s) or a professional who can help. Remember, you can skip a question if you are not comfortable answering. THINGS YOU HAVE DONE IN THE PAST 3 MONTHS These next questions ask about things that you got in trouble for or things that you did that you could have gotten in trouble for during the last 3 months. A few of these questions ask about drugs. Some kids have used one or more of these drugs and others have not. There are no right or wrong answers. Please be as honest as you can. Remind yourself how long ago 3 months was by writing something that happened in your life close to that time: Put an X in the box that fits best 0 times 1 or 2 times 3 or more times In the past 3 months, I got in trouble or could have gotten in trouble for: a. Skipping school (even just part of a day) without parent permission.    b. Getting high using a pain reliever (such as Oxycontin, Vicodin, or Fentanyl) or heroin.    c. Getting high using any other drugs or substances.    d. Using tobacco or a vaporizer (such as, cigarettes, e-cigarettes, JUUL, cigars, or chewing tobacco).    e. Running away from home.    f. Drinking alcohol.    g. Participating in a gang.    h. Doing something else, not mentioned above, that could be against the law (for example, stealing something from a store, damaging public property on purpose, or breaking into a house or building without permission).    Put an X in the box that fits best In the past 3 months, I: No Yes a. Got stopped by the police for something they thought I did.   b. Was arrested.   c. Had to stay at a juvenile detention facility.   5 These next questions ask about things that may have happened to you in the past 3 months of school. If it is summer, think about the last 3 months of school before your break started. Put an X in the box that fits best In the past 3 months of school, I: 0 times 1 or 2 times 3 or more times a. Had to have a parent or guardian come to school about a problem with my behavior.    b. Had to see the principal or other staff person at school because of an issue with my behavior (but didn’t get a suspension or detention for it).    c. Got sent to detention (either during school, afterschool, or on a weekend) because I got in trouble.    d. Got suspended (I was not allowed to come to school for one or more days) because I got in trouble.    YOUR MOODS AND FEELINGS These last questions ask about how you might have felt recently. For each sentence, think about how often you have felt this way in the past week. Put an X in the box that fits best In the past week: Never Almost Never Sometimes Often Almost Always a. I could not stop feeling sad.      b. I felt alone.      c. I felt everything in my life went wrong.      d. I felt happy.      e. I felt like I couldn’t do anything right.      f. I felt lonely.      g. I felt sad.      h. I felt unhappy.      i. It was hard for me to have fun.      j. I felt proud.      THANK YOU!