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): (Required.)

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:

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2. What is your Gender (Required.)

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3. What is your age? (Required.)

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): (Required.)

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 (Required.)

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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? (Required.)

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? (Required.)

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)? (Required.)

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:

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

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* 2. What is your Gender (Required.)

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* 3. What is your age? (Required.)

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

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* 5. What is your ethnicity (Required.)

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* 6. What is your approximate average household income?

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

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

Question Title

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

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

2. What is your Gender (Required.)

3. What is your age? (Required.)

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

5. What is your ethnicity (Required.)

6. What is your approximate average household income?

7. In which of the following communities do you live? (Required.)

8. In which of the following communities do you work? (Required.)

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