Bullying Prevention Student Survey Pathways Question Title * 1. School District Question Title * 2. School Name Question Title * 3. Grade Question Title * 4. Gender Boy Girl Question Title * 5. Do you like school? Nope not at all Nope Kinda Yeah Love it! Question Title * 6. Do you know your school Bullying Policy? Nope Kinda Yep What's a policy? Question Title * 7. Since beginning of year what describes you best? I have been bullied. I have bullied another person. I have seen bullying with others, but was not involved. All of the above. None. Question Title * 8. What type of of bullying have you been part of, or witnessed? Check all that apply. Verbal Physical Social Cyber None Question Title * 9. About how many times? Daily Once or twice a week Once or twice a month Once or twice since school started I have not been bullied Question Title * 10. How were you bullied? Check all that apply. Called names, made fun of or teased in a hurtful way Students left me out of things on purpose, excluded me from their group of friends or ignored me Hit, kicked, pushed, shoved around, or locked indoors Lies told about me or false rumors told so others would not like me Money or personal things were taken or my property was damaged Threatened or forced to do something I didn't want to do Other (please specify) Question Title * 11. Where does bullying happen? Choose all that apply. School Bus Cafeteria area Hallways Bus stop Classroom with teacher in room Classroom without teacher in room Bathroom Locker room/PE Cyberspace Playground/athletic field Other (please specify) Question Title * 12. Who have you talked to about bullying? Choose all that apply. Counselor None Your teacher Principal Another adult at school Parents or guardian Sibling Friends Other (please specify) Question Title * 13. Who would you feel comfortable talking to about bullying? Choose all that apply. Sibling Counselor None Your teacher Principal Another adult at school Parents or guardian Friends Other (please specify) Question Title * 14. Comments about bullying: Question Title * 15. I feel bullying is a concern at my school. Never Almost Never Sometimes Often Always Question Title * 16. I feel safe at my school. Never Almost Never Sometimes Often Always Next