IYSA Assessment Entry Form

IYSA Outcome Assessment:  
Youth ID:   DOB:  (mm/dd/yyyy) Entry Date: Click Here to Pick up the date  Enterer:  Exit Assessment #: 

*** Please Note: You have 20 minutes to complete this form. All data will be lost if you try to save after 20 minutes.

 # Question
 1  Have you been arrested since enrolled in this program?

Yes     No

 1b  Have you been arrested in the past six months after exiting the program?

Yes     No

 2  How much harm do you think people risk (physically or in other ways) if they use tobacco, alcohol, or other drugs?

1     2     3     4     5     6     7     8     9     10

No Risk              Slight risk          Some risk         High risk           Great risk

 3  Do you think it is wrong for someone your age to get into a physical fight with someone?

1     2     3     4     5     6     7     8     9     10

Not at all           Slightly wrong        Wrong           Pretty wrong      Very wrong

 4  Putting them all together, what are your grades like now?

Mostly A's
Mostly B's
Mostly C's
Mostly D's
Mostly F's
 
 5  Have you been suspended/expelled while in this program?

Yes     No

 6  On how many occasions while participating in this program, if any, have you smoked cigarettes (including e-cigarettes), used alcohol, illegal drugs, or misused prescription drugs?

1     2     3     4     5     6     7     8     9     10

Never                   Seldom          Occasionally         Often             Every day

 7  There are adults in your life you could talk to about something important.

1     2             3     4     5     6     7     8     9     10

Strongly disagree       Disagree            Neutral             Agree           Strongly agree

 8  If you had a personal problem, you could ask your parents/guardian or other adult for help.

1     2             3     4     5     6     7     8     9     10

Strongly disagree       Disagree            Neutral             Agree           Strongly agree

 9  All in all, you believe you can accomplish things in life.

1     2             3     4     5     6     7     8     9     10

Strongly disagree       Disagree            Neutral             Agree           Strongly agree

 10  Overall, how do you get along with your family?

1     2     3     4     5     6     7     8     9     10

Not at all                A little               Somewhat             Well               Very well