Anti-bullying Parent/Adult Survey

Disclaimer: This survey is purely to gather information, it is not meant to assess, diagnose, or treat a mental health condition. If you would like additional information and resources on bullying, please check out this website: http://www.stopbullying.gov/

Information on survey taker:

Question Title

* 1. I would identify myself as (check all that apply):

a. Parent

b. Adult who was bullied as a child (must now be 18 years or older)

c. Adult who was a bully as a child (must now be 18 years or older)

Other (please specify)

Demographic Information:

Question Title

* 2. What is your Gender

Question Title

* 3. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

Decline to State

Question Title

* 4. Ages of children (check all that apply):

i. 0-5

ii. 6-11

iii. 12-14

iv. 16-18

v. 18+

vi. Decline to State

Vii No Children

Question Title

* 5. What is your ethnicity

Question Title

* 6. What is your approximate average household income?

$0-$24,999

$25,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$124,999

$125,000-$149,999

$150,000-$174,999

$175,000-$199,999

$200,000 and up

Decline to State

Question Title

* 7. In which of the following communities do you live?

i. East Los Angeles County: Eastside, San Gabriel Valley, Pomona Valley

ii. West Los Angeles County: Westside, Beach Cities

iii. Southern Los Angeles County: South Bay, Palos Verdes Peninsula, South Los Angeles, Gateway Cities, Los Angeles Harbor Region

iv. Northern Los Angeles County: San Fernando Valley, portions of the Conejo Valley, portions of the Antelope Valley and Santa Clarita Valley

v. Central Los Angeles: Downtown Los Angeles, Mid-Wilshire

vi. Outside of this area

Question Title

* 8. In which of the following communities do you work?

i. East Los Angeles County: Eastside, San Gabriel Valley, Pomona Valley

ii. West Los Angeles County: Westside, Beach Cities

iii. Southern Los Angeles County: South Bay, Palos Verdes Peninsula, South Los Angeles, Gateway Cities, Los Angeles Harbor Region

iv. Northern Los Angeles County: San Fernando Valley, portions of the Conejo Valley, portions of the Antelope Valley and Santa Clarita Valley

v. Central Los Angeles: Downtown Los Angeles, Mid-Wilshire

vi. Outside of this area

Question Title

* 9. What is your relationship to bullying (check all that apply)?

a. I have been bullied.

b. I was a bully.

c. My child or someone I know has been bullied.

d. My child or someone I know has been a bully.

e. I have witnessed bullying.

f. I have intervened during or after a bullying event.

g. I have never been part of or witnessed a bullying event.

h. Other: