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NOTE: THIS TEMPLATE IS NOT BUILT FOR OR INTENDED FOR DISTRIBUTION TO MINORS UNDER 16 (OR A HIGHER AGE DEPENDING ON YOUR LOCATION). Visit the Acceptable Uses Policy for more information.

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1. During the last week, how many times, if any, has someone made fun of you, called you names, or insulted you?

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2. During the last week, how many times, if any, has someone spread rumors about you?

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3. During the last week, how many times, if any, has someone pushed you, shoved you, tripped you, or spit on you?

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4. During the last week, how many times, if any, has someone threatened you with harm?

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5. During the last week, how many times, if any, has someone tried to make you do things you did not want to do; for example, give them money or other things?

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6. During the last week, how many times, if any, has someone destroyed your property on purpose?

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7. During the last week, how many times, if any, has someone left you out of or wouldn't let you join in activities on purpose?

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8. During the last week, how many times, if any, has someone used cell phones or the Internet to say or post hurtful things about you?

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9. About how many students attend your school?

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10. What are the lowest and highest grades taught at your school?

0 of 10 answered
 

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