Well-Being and Health Youth Survey - Junior (Grade 4 to 6)

Your school board and Wellington-Dufferin-Guelph Public Health are inviting you to participate in a survey. We want to learn about the well-being and health of students like you.

What is the purpose of the survey?

The survey asks about your health and well-being so that we can understand your needs. Your answers to this survey and the answers of your classmates will help us plan programs to make your school and our community a better place to live.

What we are asking you to do:

We want you to answer the questions on this 30-minute survey.  There are no right or wrong answers. Do not spend too much time on any one question. Go with the answer that first comes to your mind. Please read each question carefully and answer honestly. If you don’t know the answer to a question, leave it blank. You can also skip any question if it makes you uncomfortable. 

If you need help filling out this survey, please talk to your teacher.

Do you have to do this survey?

You do not have to do this survey. It is up to you.  You can say no now or you can even change your mind later.  No one will be upset with you if you decide not to do this survey.

Your grades and your relationships with your school, teachers and public health will not be affected if you choose not to do the survey or if you choose to stop at any point. If you do choose to stop, you can choose to delete your answers or keep your answers. If you keep your answers, we can still use those answers to help us understand student health. Once you’ve finished the survey or if you close your internet browser suddenly, you can’t delete any answers and they will be saved.

Could this survey hurt or help you in any way?

Some questions in this survey might make you feel uncomfortable and you don’t have to answer those if you don’t want to. If you feel uncomfortable after doing this survey, you can talk to your guidance counsellor or call the Kids Help Phone (1-800-668-6868). This survey could help you because we will use the answers to improve your community and school.

What will we do with information about you?

When you finish the survey, your answers will go to Public Health. Your answers will not be seen by anyone at your school, including your teachers and parents. Public Health will be very careful to keep your answers to the survey private. Public Health will keep all information we collect about you locked up and password protected. They will take all information from all students who do this survey to create reports for schools, the community, and other professionals. Your name or any other information that could tell us who you are will not be used in any reports. The reports will be available on the Report Card Coalition Website: www.wdgreportcard.com. Data collected from the survey will be kept on a secure network for at least six years.

This survey has received an approval from an ethics review. If you have questions about this, contact Jennifer MacLeod at 1-800-265-7293 ext. 4370 or by email at jennifer.macleod@wdgpublichealth.ca

If you have any other questions, you can contact:
Blair Hodgson
Wellington-Dufferin-Guelph Public Health
Phone Number: 1-800-265-7293 ex. 4312
Email Address: blair.hodgson@wdgpublichealth.ca

Do you agree to take the survey?

  •  Yes
  •  No   

The information on this form is collected under the authority of the Health Protection and Promotion Act in accordance with the Municipal Freedom of Information and Protection of Privacy Act and the Personal Health Information Protection Act. This information will be used for the delivery of public health programs and services; the administration of the agency; and the maintenance of health-care databases, registries and related research, in compliance with legal and regulatory requirements. Any questions about the collection of this information should be addressed to the Chief Privacy Officer at 1-800-265-7293 ext 2975.


  1. To begin, which Township or City do you live in?  Ask your teacher if you are unsure. (Drop down list)

Question 2 is only shown to students who live in Guelph (Question 1)

  1. Please enter your six-digit postal code (no spaces or dashes). If you don’t know your postal code, please leave it blank.


  1. What grade are you in? (Drop down list)
  2. What is the name of your school? (Drop down list: school names)
  3. What is your gender?
  •  Female (girl)
  •  Male (boy)
  •  I identify as something else. How do you identify? ________________
  1. Were you born in Canada?
  • Yes
  • No   
  1. What languages do you speak at home? (If you and your family speak more than one language, please select all languages that you speak at home.)
  •   Arabic
  •   Cantonese
  •   Dutch
  •   English
  •   French
  •   German
  •   Gujarati
  •   Hungarian
  •   Indigenous language(s)
  •   Mandarin
  •   Persian (Farsi)
  •   Polish
  •   Punjabi (Panjabi)
  •   Spanish
  •   Tagalog (Pilipino, Filipino)
  •   Urdu
  •   Vietnamese
  •   A language not listed above (please specify: __________)
  1. Do you identify as an Indigenous person (First Nations, Métis, and/or Inuit)? Choose any that apply.
  •   First Nations
  •   Métis
  •   Inuit
  •   I do not identify as First Nations, Métis or Inuit
  •   I don’t know if I am an Indigenous person
  •   I don’t understand this question

People are often described as being part of a “race” based on how they look or where in the world their families are from.

  1. Which racial group(s) best describes you? If you have a mixed background, please choose all that apply.

 Hover over an answer with your mouse to see examples (bracketed text)

  •   Black                                 (For example: African, Afro-Caribbean, African-Canadian)
  •   East Asian                         (For example: Chinese, Korean, Japanese, Taiwanese)
  •   Indigenous                        (For example: First Nations, Métis, Inuit)
  •   Latino/Latina/Latinx         (For example: Latin American, Hispanic descent)
  •   Middle Eastern                 (For example: Lebanese, Afghan, Egyptian, Iranian, Turkish, Kurdish)
  •   South Asian                      (For example: Bangladeshi, Indian, Pakistani, Sri Lankan)
  •   Southeast Asian               (For example: Cambodian, Filipino, Indonesian, Thai, Vietnamese)
  •   White                                (For example: English, French, German, Polish, Italian)
  •   A racial group not listed above (please specify ________________________)
  •   I don’t know what race(s) I am
  •   I don’t understand this question

Your Community

  1. Please describe how you feel about your neighbourhood.



Sometimes/ Sort of


I don’t Know

a) I feel safe in my neighbourhood





b) My neighbours care about me





Your School

  1. Please describe how you feel about your school:



Sometimes/ Sort of


a)    I am an important part of my school community




b)    My education is important to me




c)     I get the support I need to learn at school




d)    I am interested in what I am learning at school




e)    My parents/guardians and teachers work with me to help me learn




f)     I take part in school activities like clubs or sports




  1. How do you feel about school?
  •   I love school
  •   I like school
  •   I do not really care either way
  •   I do not like school very much
  •   I hate school
  1. Do you agree with the following statements?
  Yes Sometimes/
Sort of

a)    I feel safe at my school


b)   I feel included at my school


Question 14 is only shown to students who answer “no” to feeling safe at school (Question 13 a).

  1. When you DO NOT feel safe at school, is it because of any of the following?

Please check ALL that apply

  •   My own or my family’s background (race, ethnicity, religion, culture, Indigenous background,)
  •   Where my family came from, the language we speak, or traditions that we practice
  •   How much money my family has
  •   My gender, sexual orientation, or gender identity
  •   My grades, or how smart I am
  •   A disability or special need that I have
  •   Other (please specify _________________)

Question 15 is only shown to students who answer “no” to feeling included at school (Question 13 b).

  1. When you DO NOT feel included at school, is it because of any of the following?

Please check ALL that apply)

  •   My own or my family’s background (race, ethnicity, religion, culture, indigenous background,)
  •   Where my family came from, the language we speak, or traditions that we practice
  •   How much money my family has
  •   My gender, sexual orientation, or gender identity
  •   My grades, or how smart I am
  •   A disability or special need that I have
  •   Other (please specify ___________________)
  1. Please describe how you feel about the adults at your school.
  Yes Sometimes/
Sort of

a)    Adults at my school have high expectations of me


b)    Adults at my school are interested in me


c)     Adults at school notice when I am doing a good job and let me know about it

  1. Is there at least one adult at school you can turn to if you need help?
  •  Yes
  •  No


Bullying refers to the same person or people hurting your body or feelings on purpose over and over again. Bullying can include lots of different things like name-calling, spreading rumours, hitting, breaking someone’s things, cyberbullying or leaving someone out on purpose. If you are being bullied, it’s important to talk about it with an adult that you trust.

  1. IN THE LAST 12 MONTHS, have you been bullied AT SCHOOL OR ON THE BUS?
  •   Never
  •   A Few Times
  •   Often
  •   Almost Every Day
  1. IN THE LAST 12 MONTHS, have you been bullied WHEN YOU WERE NOT AT SCHOOL?
  •   Never
  •   A Few Times
  •   Often
  •   Almost Every Day

Question 20 is only shown to students who answered that they have been bullied (Questions 18 & 19)

  1. Did you tell an adult about the bullying?
  •   Yes
  •   No

Question 21 is only shown to students who answered “yes” to telling an adult about the bullying (Question 20)

  1. Who was the adult that you told? Please check ALL that apply
  •   A teacher
  •   Principal or Vice-Principal
  •   A staff member at school
  •   Parent or guardian
  •   A family member
  •   A police officer
  •   Other (please specify _____________________)

Question 22 is only shown to students who answered “yes” to telling an adult about the bullying (Question 20)

  1. Did the adult(s) help you?
  •   Yes
  •   No

Question 23 is only shown to students who answered that they have been bullied (Questions 18 & 19)

  1. Who bullies you? (Check all that apply)
  •  Other students
  •  Kids outside of my school
  •  Siblings
  •  Teachers
  •  Coach/Instructors
  •  Parents
  •  Other adults I know
  •  People you met online
  •  Other

Question 24 is only shown to students who answered that they have been bullied (Questions 18 & 19)

  1. IN THE LAST 12 MONTHS, were you bullied in these ways:

Check ALL that apply

  •   Physical Aggression (e.g., pushed, tripped, or hit)
  •   Verbal Aggression (e.g., repeatedly teased, insulted, or called hurtful names)
  •   Electronic/Cyberbullying (e.g., teased through social media, or text messages)
  •   Someone damaging something that belonged to you on purpose
  •   Someone leaving you out or excluding you on purpose

Question 25 is only shown to students who answered that they have been bullied (Questions 18 & 19)

No one deserves to be bullied. There is never a good reason for someone to bully you.

  1. Why do you think others were bullying you? (Check all that apply)
  •  I don’t know why I’ve been bullied
  •  Race, culture, or skin colour
  •  Weight
  •  Appearance (other than because of race, culture, or weight)
  •  Sexual orientation
  •  Gender identity
  •  Religion or faith
  •  Interests, activities or hobbies
  •  Language
  •  What my family can afford to buy
  •  Disability or special need
  •  School grades
  •  Other reasons

Your Friends

  1. Please answer the following statements about your friends.
  Yes Sometimes/
Sort of
a)  I have many friends      
b)  I get along well with other kids my age      
c)  Other kids my age want me to be their      
d)  Most other kids my age like me      
e) I have at least one good friend who cares about me      

Your Family

  1. Please answer these statements about your family.
  Yes Sometimes/
Sort of

a)     My parents/guardians listen to my ideas


b)    My parents/guardians and I solve a problem together if we disagree about something


c)     My parents/guardians show me I am cared about


d)    I spend quality time at home with my family


e)    My parents/guardians talk about the good things that I do



  1. Overall, how would you rate your physical health? (How healthy is your body?)
  •   Excellent
  •   Very Good
  •   Good
  •   Fair
  •   Poor
  1. In general, how often do you eat fruits and vegetables every day?
  •  Less than once a day
  •  Once a day
  •  A few times a day
  1. IN A USUAL SCHOOL WEEK (Monday to Friday) how often do you eat breakfast?
  •  Rarely/Never
  •  1-2 days per week
  •  3-4 days per week
  •  All 5 days
  1. ON A SCHOOL NIGHT, what time do you usually go to sleep? (Drop down list)
  2. ON A SCHOOL DAY, what time do you usually get up in the morning? (Drop down list)
  3. IN A USUAL SCHOOL WEEK (Monday to Friday), how often do you walk (or bike or skateboard) to or from school? Don’t count the weeks when the weather was too cold, snowy or rainy to walk.
  •  It is too far for me to walk or bike
  •  I could walk or bike but I rarely/never do
  •  1-2 days per week
  •  3-4 days per week
  •  All 5 days

Physical activity is any anything that makes your heart beat fast, can make you sweat and may make you lose your breath sometimes. Some examples of physical activity are running, walking fast, rollerblading, biking, dancing, skateboarding, swimming and playing sports.

  1.  IN A TYPICAL WEEK, on how many days are you physically active for a total of at least 1 hour per day?
  •  0 days
  •  1 day
  •  2 days
  •  3 days
  •  4 days
  •  5 days
  •  6 days
  •  7 days
  1. OUTSIDE OF SCHOOL HOURS, on average about how many HOURS a day do you spend on screens (For example, playing video games, using a cell phone, tablet or the computer, or watching TV/DVD’s)?
  •  Less than 1 hour a day
  •  1 or 2 hours a day
  •  3 or 4 hours a day
  •  5 or 6 hours a day
  •  7 or more hours a day

Mental Health

  1. How would you describe your:





Very Good


a)    Mental health






b)    Happiness






  1. Please check the box that best describes you.
  Yes Sometimes/
Sort of

a)     I deal with problems in positive ways


b)    I feel good about myself


c)     I like the way I look


d)     I feel proud of myself


e)     I feel hopeful about my future


f)     I handle problems at school well

  1. IN GENERAL, how often do you feel:


Often/ Always


Rarely/ Never

a)    Sad




b)    Lonely




c)    Worried




d)    Angry




  1. IN THE LAST YEAR, have you had trouble with…





a)    Being distracted (feeling like you can’t pay attention)




b)     Pressure from other kids




c)     Stress about school work  




d)     Feeling like hurting yourself




  1. Do you have at least one adult in your life who you can talk to about your problems (such as a teacher, coach or parent/guardian)?
  •  Yes
  •  No

Cigarettes, Alcohol and Other Drugs

  1. Have you ever tried any of the following?
  Yes No
a)     Cigarettes    
b)    Alcohol (more than a few sips)    

c)     Cannabis (also known as marijuana, weed, grass, pot, hashish)


d)    Other drugs not given to you by a doctor or your parents


You have reached the end of the Well-Being and Health Youth Survey!

 Thank you for taking the time to share your experiences with us. The answers you gave will be used to help improve your school and your community.

 Click the “Submit” button below to save your answers and close the survey.