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Survey Templates Surveys Self-Injurious Behavior and Related School-Based I

Self-Injurious Behavior and Related School-Based I

Sample Survey


Hello:

You are invited to participate in a survey designed to gather data on the topic of self-injury. We are interested in educating school personnel on the topic, as well as developing school-based interventions in order to provide support and care to students. In this survey, approximately 500 people will be asked to complete a survey that asks questions about their history, feelings, and habits involving self-injury. It will take approximately 15 minutes to complete the questionnaire. The study is being conducted by University of Kentucky graduate student, Jessica Shoemake, under the direct supervision of Dr. H. Thompson Prout. Both are affiliated with the School Psychology department at the Univeristy of Kentucky.


Your participation in this study is completely voluntary. Material covered in the survey may be triggering. If you feel uncomfortable answering any questions, or feel triggered by any of the material, you can withdraw from the survey at any point. If you chose to withdrawl from the survey, please go to the last page and view the list of links provided to offer support and help to deal with the negative feelings you may be experiencing.


Your survey responses will be stricly confidential, and data from this research will only be reported once it is combined with the data from other participants. Your information will be coded and kept confidential. You will not be asked to provide any identifying information, such as name, email address, or birth date. Due to the online nature of the survey, it is possible for third parties to intercept electronic data transmissions; therefore, it cannot be guaranteed that all information submitted via the internet will be private. If you have questions at any time about the survey or the procedures, you may contact Jessica Shoemake at (270) 706-8009, or by email at [email protected].


Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below. Once again, there are several links to online support/information groups listed on the final page of the survey.


Age
Race
Gender
What method(s) of self-injury do you use?
At what age did you begin using self-injury as a way to deal with negative feelings?
Why do you self-injure?
How do you feel before you self-injure?
How do you feel while you are injuring?
How do you feel immediately after you injure yourself?
Have you ever sought treatment for your self-injury?
If so, what were the reactions of those you went to for help?
How did their reactions make you feel about seeking help in the future?
Have you sought help or support from any school employee (i.e. teacher, counselor, nurse)?
If so, what were the reactions of those you sought help from?
How did their reactions make you feel about seeking help in the future?
If support and treatment were offered in a school environment, would you take advantage of the services offered?
What types of services would you like to see offered in a school environment?
Would you feel comfortable telling your parents about your self-injury in order to receive serivces offered in a school environment? If not, why?
Additional Comments:
The following are links to various online support/help sites for those who self-injure.

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