* 1. In my classroom I feel...

* 2. On the playground I feel...

* 3. In the cafeteria I feel...

* 4. In the restrooms I feel...

* 5. Other kids hit, kick or push me...

* 6. Other kids say mean things to me...

* 7. Other kids steal or destroy my property...

* 8. This year, who has bullied you, said mean things to you, teased you, called you names or tried to hurt you at school?

* 9. In what grade is the student or students who bully you?

* 10. If you have been bullied this year, who have you told?

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