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* 1. I am a:

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* 2. What grade are you in?

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* 3. When I cannot stop the bullying on my own I (Check any that are true for you):

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* 4. I have been physically or emotionally hurt by bullying when I have been a (Check any that are true for you):

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* 5. For me, the biggest hurt of bullying comes from (Check up to 3 answers)

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* 6. One way that I try to stop bullying is:

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* 7. What is one thing you would like to share with your teachers or counselors about bullying that you have seen happen?

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* 8. Please rate the following statements.

  Strongly Disagree Disagree Neutral Agree Strongly Agree
I liked the RESPECT play that I saw today.
I learned new ways to help myself when I am being bullied.
I learned new ways to help others when they are being bullied.
I learned about new people or resources to go to if I need help with bullying.
I plan on using some of these new ways to stop bullying as soon as I can.

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* 9. Please give an example of a way that you plan to stop bullying.

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