Healthy Student Relationships Survey- Students

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1. During this school year, how many times have you been made fun of, been called names or have been insulted?

2. During this school year how often have you been pushed, tripped or shoved on purpose?

3. During this school year how often has someone threatened to hurt you?

4. During this school year, 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?

5. During this school year how many times have you felt left out or were told that you could not join in a game or activity?

6. During this school year how many times have you not wanted to go to school because of how another child has treated you?

7. If there have been issues of concern of how you have been treated at school by other children where have they taken place?

8. How do you respond when someone has done something that has hurt you?

9. Do you feel that teachers have helped you when you have mentioned concerns with other students?

10. What grade are you in?