* 1. My school is:

* 2. My grade is:

* 3. Are you a boy or a girl?

* 4. I eat breakfast

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

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

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

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

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

* 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)

* 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)

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