Thank you for participating in this research project to better understand the lasting impacts of Nia House on our students.  

All information will remain confidential. 

ABOUT THE CHILD
Child's Date of Birth *
Child's Date of Birth
Child's race/ethnic background: *
Check all that apply.
Language your child first learned when they began to speak? *
What grade is your child in now (2018)? *
After Nia House, what type of school did your child attend? *
How many years did your child attend Nia House? *
My child is reading: *
Has your child been suspended or expelled from school? *
Check all that apply.
On average, how many days does your child miss school per year? *
My child seems interested in school. *
Select one.
ABOUT THE PARENT
Highest parent education level: *
Parent's first language or language spoken in the home: *
Parent's race/ethnic background: *
Check all that apply.
Parent's race/ethnic background:
Race/ethnic backgroud of second parent if in a two parent household. Check all that apply.
Did your family receive financial assistance while at Nia House?  *
How many people live in your home? *
What is your family's gross annual income?
Nia House academically prepared my child for elementary school: *
Nia House emotionally prepared my child for elementary school: *
Consider academic, social, and emotional skill sets.
I feel connected to and informed about my child's academic experience. *
I am able to advocate and seek support for child in their school experience. *
Are you willing to submit your child’s report card and California Standard test scores (STAR): *
May we contact you for ongoing information? *
For follow up to receive report card and test scores.
I am happy
I am happy
always
never
sometimes