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The purpose of this survey is to find out about student safety and bullying at your school. Your name is not required on this survey. Your answers are confidential, so please answer the questions honestly.

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1. Where do you currently attend school?

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2. Are you male or female?

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3. What grade are you in?

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4. Do you feel safe at school? Safe means feeling comfortable, relaxed, and not worried that someone could harm you.

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5. Do you feel safe on your way to and from school?

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6. Do you feel safe on the school bus?

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7. Who do you talk to when you have problems at school?

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8. When you answer the next questions, think about THE PAST FOUR MONTHS.

Have you been bullied by other students physically?
(Examples: pushed, hit, slapped, kicked, had belongings damaged or stolen)

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9. When you answer the next questions, think about THE PAST FOUR MONTHS.

Have you been bullied by other students socially?
(Examples: excluded from a group, made to look dumb by someone, gossiped about, rumors spread)

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10. When you answer the next questions, think about THE PAST FOUR MONTHS.

Have you been bullied by other students electronically?
(Examples: threatened, embarrassed, singled out, had your feelings hurt, been gossiped about, or had secrets about you revealed through e-mail or phone text messages or pictures)

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11. When you answer the next questions, think about THE PAST FOUR MONTHS.

Have you been bullied by other students racially?
(Examples: treated differently or badly because of your race, culture, ethnicity)

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12. When you answer the next questions, think about THE PAST FOUR MONTHS.

How often have you seen or heard another student being bullied physically?
(Examples: pushed, hit, slapped, kicked, had belongings damaged or stolen)

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13. When you answer the next questions, think about THE PAST FOUR MONTHS.

How often have you seen or heard another student being bullied by other students socially?
(Examples: excluded from a group, made to look dumb by someone, gossiped about, rumors spread)

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14. When you answer the next questions, think about THE PAST FOUR MONTHS.

How often have you seen or heard another student being bullied electronically?
(Examples: threatened, embarrassed, singled out, had your feelings hurt, been gossiped about, or had secrets about you revealed through e-mail or phone text messages or pictures)

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15. When you answer the next questions, think about THE PAST FOUR MONTHS.

How often have you seen or heard another student being bullied by other students racially?
(Examples: treated differently or badly because of your race, culture, ethnicity)

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16. How often have you stayed away from school in order to avoid being bullied?

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17. How often have you tried to help another student who was being bullied?

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18. Where does bullying in or near your school occur? Choose all that apply.

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19. Think of the last time you saw or heard another student being bullied. What did you do? Check any that are true.

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20. How can the following people prevent bullying at school?

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