* 1. Today's Date:

Date:
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* 2. Gender:

* 3. Grade:

* 4. Teacher:

Bullying occurs when an individual or a group of people use their power unfairly to hurt someone on purpose. This can happen in many different ways. It can be physical such as hitting, kicking, and pushing. It can be verbal such as saying mean things, teasing, or calling someone names. It can be social such as making fun of someone, leaving someone out or making sure others leave someone out, and spreading rumours. Bullying can also take place over the phone, on the computer, and by other electronic means. We are going to ask you some questions about bullying at your school. Your answers will help us to gain a better understanding of what your day is like at school and how people get along with each other. We appreciate your honest answers and you do not need to write your name on this form unless you choose to do so. The questions refer to things that have happened in the last two months.

* 5. How often have you been bullied at school? (Check one answer)

* 6. Where does bullying happen at your school (Check as many responses as you want)

* 7. When does the bullying take place? (Check as many as you want)

* 8. How have you been bullied at school? (Check as many as you want)

* 9. Has anyone bullied you at school for any of these reasons. (Check as many as you want)

* 10. Do students at your school try to stop bullying when it happens?

* 11. If you have been bullied at school, what did you do? (Check as many as you want)

* 12. What do you think adults at school should do to help if students are being bullied? (Check as many as you want)

* 13. What do adults in your school do when bullying occurs?

* 14. If you have been bullied at school, who bullies you?

* 15. How often have you taken part in bullying others at school? (Check one)

* 16. How would you describe your part in bullying at school? (Check as many as you want)

* 17. Have you seen or heard about students at your school being bullied?

* 18. If you have seen bullying at school, what did you do? (Check as many as you want)

* 19. Have you been bullied anywhere else in the past 2 months? (Check as many as you want)

* 20. If you have been bullied outside of school, did you speak to anyone about it?

* 21. Did it help to talk to someone about it?

* 22. If you want to speak to someone about your concerns, please print your name here:

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