Secondary

 1. 

“Bullying” is repeated behavior by an individual or group that is intended to cause the victim to feel frightened, threatened, intimidated, humiliated, shamed, disgraced, ostracized, or physically abused.

ABOUT YOU

What grade are you in?
         
  9
  10
  11
  12
 
 2. Do you feel safe at school?
         
      
 
 3. Do you feel welcome at school?
         
      
 
 4. Is there an adult at school you talk to when you have a personal problem and need help?
         
      
 
 5. Have YOU been bullied at school?
         
      
 
 6. Have YOU been bullied verbally?
         
      
 
 7. Have YOU been bullied physically?
         
      
 
 8. Have YOU been bullied emotionally?
         
      
 
 9. Have YOU been bullied through technology?
         
      
 
 10. If YOU have been bullied at school, HOW OFTEN has this happened?
         
  Never
  Sometimes
  A Lot
 
 11. If YOU have been bullied WHERE has this happened? * Choose the one where most of the bullying happens.
         
  My Classroom
  The Hallway
  The Cafeteria
  The Bathroom
  The Bus
  Locker Rooms
  I have not been bullied
  Other
 
 12. If you have been bullied, WHEN has this happened?
         
  Before school
  During school
  After School
  I have not been bullied
 
 13. If YOU are bullied do you tell your parent or guardian?
         
  Yes
  No
  I have not been bullied
 
 14. If YOU get bullied what do you do? * Choose what you do most often.
         
  I have not been bullied
  Nothing/Ignore it
  Stay away from the person
  Tell the person to stop
  Bully the person back
  Talk to an adult at school
  Tell my family at home
 
 15. Do YOU bully others at school?
         
      
 
 16. If YOU bully others at school how often do you do this?
         
  Never
  Sometimes
  A Lot
  I do not bully others
 
 17. How have YOU bullied others? * Choose what you do most often.
         
  Verbally
  Physically
  Emotionally
  Cyber-bullying
  I do not bully others
 
 18. If YOU bully others WHERE does this happen? * Choose the place where you bully others most often.
         
  My Classroom
  The Hallway
  The Cafeteria
  The Bathroom
  The Bus
  Locker Rooms
  I do not bully others
  Other
 
 19. Why do YOU bully others? * Choose the one that is most often true for you.
         
  I'm just joking around.
  To get attention from my friends and teachers
  The person bothers me
  It makes me feel powerful and in control
  I do not bully others
 
 20. ABOUT OTHERS

How often do you see OTHERS get bullied at school?
         
  Never
  Sometimes
  A lot
 
 21. Have you seen OTHERS be bullied verbally (saying mean things)?
         
      
 
 22. Have you seen OTHERS be bullied physically (hurting someone's body)?
         
      
 
 23. Have you seen OTHERS be bullied emotionally (left out, excluded on purpose)?
         
      
 
 24. Have you seen OTHERS be bullied through technology (texting, messaging, Facebook, etc.)?
         
      
 
 25. WHEN do you see OTHERS get bullied at school?
         
  Before school
  During school
  After school
  I don't see others get bullied
 
 26. WHY do YOU or OTHERS get bullied at school? * Choose the reason you think is true most often.
         
  Different color skin
  Look different
  Act different
  Talk different
  I don't know
 
 27. If you see OTHERS get bullied at school what do you do? * Choose what you do most often.
         
  I don't see others get bullied
  Nothing/ignore it
  Tell the bully to stop
  Join in the bullying
  Try to help the person who is being bullied feel better
  Tell an adult in school
  Tell my parent/guardian
 
 28. If you see OTHERS get bullied at school WHERE does this happen? * Choose what you have seen most often.
         
  My Classroom
  The Hallway
  The Cafeteria
  The Bathroom
  The Bus
  Locker Rooms
  I do not see others get bullied
  Other
 
 29. ABOUT SCHOOL STAFF

What do adults at school do if they see you or others being bullied at school? * Choose what you see happen most often.
         
  Nothing/Ignore it
  Tell the bully to stop
  Tell the person being bullied to ignore it
  Tell the person being bullied not to tattle
  Give the person bullying someone a consequence
 
 30. Do you think adults at school care about stopping bullying in your school?
         
      
 
 31. YOU CAN HELP

List the first and last name and grade of students who are being bullied.
         
    
 
 32. List the first and last name and grade of students who are bullying others.