School-Based Health Center -  Student Health Survey
As a student of Cañon City School District your ideas about needed health services are very important.  

We are planning to open a school-based health center in the new Cañon City Middle School. Your responses to this survey will help us understand what kinds of student health services are needed, such as medical care, counseling services, dental care, etc.

Your answers will be kept private.

What is a school-based health center? A school-based health center is a clinic in a school. (It is not the same as the school nurse’s office.) The clinic provides medical care, counseling and dental health services at the school. These services help students stay healthy and in school.

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1. What grade are you in? (Check one answer.) *
2. What is your gender? (Check answer.) *
3. What are the best things about your school? (Check all that apply) *
Required
4. What are the three biggest problems/challenges for your school? (Check all that apply.) *
Required
5. We would like your opinion on the health problems students at your school face? Please rate each of the problems listed below on a scale of 1-5 (1 being major, 5 being minor) for students at your school: *
1
2
3
4
5
Alcohol use
Anxiety
Asthma
Depression
Diabetes
Drugs
Overweight
No exercise
Not enough food to eat at home
Smoking
Students need glasses
Teen pregnancy
Teeth hurt/problems with teeth
6. How safe do you feel? Please rate the school on the following issues: *
Very safe
Somewhat safe
Not very safe
At risk
Great risk
How safe you feel in the school building?
How safe you feel when outside in the areas right around your school?
How safe are you from being pressured to use tobacco, alcohol and/or drugs?
How safe are you from gang violence, bullying (because of race, sexual orientation, size, etc.) or other violence in your school?
7. During the last 12 months have you (Select Yes or No for each question): *
Yes
No
Seen a dentist?
Seen a doctor or nurse?
Seen a counselor, therapist, or social worker?
8. When there is a school-based health center at CCMS, would you go there for health care? (Check one answer) *
9. If you think you would use the Center, what hours would be best for you? (Check all that apply.) *
Required
10. What school-based services do you think you and your friends might use? (Check all that apply.) *
Required
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