My school is:

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* 1. My school is:

My grade is:

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* 2. My grade is:

Are you a boy or a girl?

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* 3. Are you a boy or a girl?

I eat breakfast

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* 4. I eat breakfast

Grown-ups at my school care about kids.

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* 5. Grown-ups at my school care about kids.

I can find a grown-up to help me when needed.

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* 6. I can find a grown-up to help me when needed.

Is there a place (or places) on campus where you feel unsafe? (You may choose more than one)

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* 7. Is there a place (or places) on campus where you feel unsafe? (You may choose more than one)

What do you do if/when you feel unsafe at school? (You may choose more than one)

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* 8. What do you do if/when you feel unsafe at school? (You may choose more than one)

What have you done when another person (student or grown-up) was picking on you? (You may choose more than one)

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* 9. What have you done when another person (student or grown-up) was picking on you? (You may choose more than one)

What should you do when you feel that another person (student or grown-up) is picking on you? (You may choose more than one)

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* 10. What should you do when you feel that another person (student or grown-up) is picking on you? (You may choose more than one)

If you saw another person being picked on, grown-up included, what would you do towards the person who is being mean? (You may choose more than one)

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* 11. If you saw another person being picked on, grown-up included, what would you do towards the person who is being mean? (You may choose more than one)

Which grown ups at your school follow the ACT statement the BEST? (You can write more than one name).
(use comment box)

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* 12. Which grown ups at your school follow the ACT statement the BEST? (You can write more than one name).
(use comment box)

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