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Survey Name:
   
 
 
 
Gender?
 
Male
 
Female
 
 
 
Grade?
 
9th
 
10th
 
11th
 
12th
 
 
 
How many class periods do you take this semester
 
8
 
7
 
6
 
9
 
 
 
How many classes are for college credit?
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
8
 
 
 
How many hours of homework do you have DAILY?
 
1 hour
 
2 hours
 
3 hours
 
4 hours
 
5 hours
 
 
 
PER WEEK how much time do you spend on homework?
 
1 - 2 hours
 
3 -4 hours
 
5 - 6 hours
 
7 - 8 hours
 
9+ hours
 
 
 
PER WEEK how many hours of TV do you watch?
 
1 - 2 hours
 
3 - 4 hours
 
5 - 6 hours
 
7 - 8 hours
 
9+ hours
 
 
 
Per DAY how many times do you check facebook?
 
once
 
twice
 
3 times
 
4 times
 
5 times
 
6 + times
 
 
 
What activities are you in outside of school? (ex. Job? Sports? Choir? Band? Club Team?)
   
 
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