Classroom Belonging and Inclusive Culture Student Survey Editable

About this resource

Everything inside: 23 pages · a 7-statement student belonging survey in two versions (elementary picture-supported, secondary 5-point) · a teacher classroom observation checklist · a student response-to-inclusion observation log · a specials/paraprofessional quick check · a monthly roll-up and trend graph · a family conversation guide · a classroom climate action plan · an 18-starter phrase bank · a binder cover and 4 cut-out divider tabs · a worked, invented example.

Every classroom has a feel to it, and most teachers only find out it is off when something has already gone wrong. This file asks the students themselves, on a short survey they can actually answer, and pairs it with what an adult in the room independently sees — never a diagnosis, never a screener with a cutoff, just a data point the team can act on. Give the survey once a term, log a teacher observation on a different day, roll the two into one number a month, and use the action plan to try one focused change at a time.

WHAT IS INCLUDED — 23 pages, 516 type-in fields

Set Up And Survey The Class

• Binder Cover and Divider Tabs — a spine/cover card, 4 cut-out tabs matching the file's sections, and a 10-row "where to find things" index
• Belonging Rating Scales and Survey Item Bank — the 7 statements both surveys use, plus blank rows to define what each rating level means for your students
• Student Belonging Survey, Elementary — 7 statements, a picture-supported 3-point scale (drawn expression icons, not photos), a read-aloud script
• Student Belonging Survey, Secondary — the same 7 statements, a 5-point self-administered scale
• Survey Administration and Class Roster — 12 rows: date, class, grade band, version used, students enrolled, surveys collected

Observe The Classroom

• Teacher Classroom Observation Checklist — 8 observable items (engagement, positive peer interaction, inclusive language, multiple ways to participate, and more), each with a real type-in Y / N / NOT OBSERVED mark
• Student Response to Inclusion Observation Log — 8 rows: date, activity, how the student was included, and whether the response observed was engaged, hesitant, or withdrew — one row is one moment, never a pattern on its own
• Specials / Paraprofessional Quick Climate Check — two half-page notes per sheet, cut apart, for the art, music, PE or para adult who sees the class somewhere the classroom teacher does not
• Monthly Belonging-Climate Score Roll-Up — 12 rows: surveys collected, positive responses, total possible responses, percent positive (the file does not calculate the percentage for you)
• Belonging-Climate Trend Graph — a 0–100 percent-positive line across 12 surveys/months, with a 2-row data table

Plus a Start Here quick-start, a 3-section contents page with real page thumbnails, 3 section dividers, and a "what's next" back page.

What This Is, And What It Is Not

It is a fillable PDF. Open it in a PDF reader, click a field, type or check a box, Save As once per class. It works offline with no account or subscription. It is NOT a Google Sheets file, a Google Doc, or an Excel workbook, and it does not score, grade, or set a cutoff for a survey.

It is not Social Skills Progress Monitoring and Peer Interaction Data Sheets Editable or Emotional Regulation and Coping Skills Data Sheets Editable — both track a skill one student is already being taught, against a goal. This file asks a different, earlier question of a whole room: do the students say the room feels welcoming and inclusive, and what does an adult independently see. Use this file to notice a classroom-wide pattern; use those two files once a pattern points at one student's own goal.

It is not a screener, not an assessment with a cutoff score, not a counseling curriculum, and not a tool that names a condition. A low score anywhere in this file is a data point for the team to act on — never a finding about one student's clinical status, eligibility, or a label for that student. No page decides what a rating level means or what counts as a pattern; the team writes that in, from its own judgment. No age, eligibility or IDEA-timeline claim anywhere; no health data is pre-filled, and the example class, teacher and student (Ms. Alvarez, Room 14, and J.M.) are invented and named as such on page 22.

Who This Is For

Classroom teachers, school climate coordinators, counselors and case managers who want a structured, honest read on how welcome and included students feel in one room — plus a second, simplified page for the specials teacher or paraprofessional who sees the class somewhere else.

If You Want More

Social Skills Progress Monitoring and Peer Interaction Data Sheets Editable and Emotional Regulation and Coping Skills Data Sheets Editable are the 19-page skill-tracking siblings for the student whose goal a pattern here points toward. School Counselor and Social Work Session Data Sheets Editable is the 22-page caseload-wide clipboard this survey pairs with next.