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* 1. Please indicated how strongly you agree or disagree with these statements.

  Strongly Agree Agree Disagree Strongly Disagree
I feel safe at Cudahy Middle School (CMS).
Students at CMS get along well with each other.
It is easy to make friends here at CMS.
There are opportunities at CMS for students to get to know each other.
Teachers at CMS actively work to create a safe and welcoming environment for every student.
I feel like I belong here at CMS.

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* 2. At Cudahy Middle School, I have been teased or called names that I do not like. (Check all that apply.)

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* 3. Other students have threatened to hurt me at CMS.

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* 4. Other students have physically hurt me at CMS.

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* 5. Other students have spread rumors about me at CMS.

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* 6. I have experienced unwanted sexual attention here at Cudahy Middle School (ie. gestures, jokes, comments, looks, touching).

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* 7. When I have seen other students being bullied/harassed in school, I have tried to stop it.

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* 8. The adults at CMS try to stop bullying/harassment.

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* 9. I feel comfortable reporting harassment or bullying to CMS staff members.

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* 10. I have witnessed bullying or harassment in these places at my school. (Check ALL that apply.)

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* 11. Would you be interested in joining a group that is dedicated to addressing the problem of bullying, inclusiveness, and fairness in school?

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