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* 1. What grade are you in?

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* 2. How old are you?

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* 3. Do you feel unsafe at JFK because of ... (check all that apply to you.)

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* 4. During the past month of school, on how many days did you not go to school because you felt you would be unsafe at school or on your way to or from school?

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* 5. Do you avoid these spaces at school because you feel uncomfortable or unsafe in the space?  (Please check all that apply to you.)

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* 6. In this school year, how often have you been verbally harassed (name-calling, threats, etc. directed at you) at your school because of...

  Never Rarely Sometimes Often Frequently
Your race or ethnicity or because people think you are of a certain race or ethnicity
Your sexual orientation (for example being gay, lesbian or bisexual) or what people think your sexual orientation is
Your gender
How you express your gender (how traditionally "masculine" or "feminine" you are in your appearance or in how you act)
Your disability or because people think you have a disability
Your religion or because people think you are of a certain religion
Your body type (size, weight, height, etc.)

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* 7. In the past year, how often have you been physically harassed (shoved, pushed, etc.) at your school because of...

  Never Rarely Sometimes Often Frequently
Your race or ethnicity or because people think you are of a certain race or ethnicity
Your sexual orientation (for example, being gay, lesbian, or bisexual) or what people think your sexual orientation is
Your gender
How you express your gender (how traditionally "masculine" or "feminine" you are in your appearance or in how you act)
Your disability or because people think you have a disability
Your religion or because people think you are of a certain religion
Your body type (size, weight, height, etc.)

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* 8. In the past year, how often have you been physically assaulted (punched, kicked, injured wit ha weapon, etc.) at your school because of...

  Never Rarely Sometimes Often Frequently
Your race or ethnicity or because people think you are of a certain race or ethnicity
Your sexual orientation (being gay, lesbian, or bisexual) or what people think your sexual orientation is
Your gender
How you express your gender (how traditionally "masculine" or "feminine" you are in your appearance or in how you act)
Your disability or because people think you have a disability
Your religion or because people think you are of a certain religion
Your body type (size, weight, height, etc.)

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* 9. In the past year how often have you been sexually harassed at your school, such as sexual remarks made toward you or someone touching your body inappropriately?

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* 10. In the past year, how often have you had mean rumors or lies spread about you by students at your school?

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* 11. In the past year, how often have you felt excluded or "left out" on purpose by students at your school?

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* 12. In the past year, how often have you had your property stolen or damaged, such as your books, backpack, clothing, etc. in school?

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* 13. In the past year, how often have you been harassed or threatened by students at your school using the phone or internet (text messages, facebok, snapchat, Instagram

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* 14. In the past year, how often have you been bullied or harassed in the following places?

  Never Rarely Sometimes Often Frequently Not Applicable - I don't have at my school
Bathrooms
Cafeteria or lunchroom
Hallways or stairwells
School athletic fields or facilities
School buses
PE or gym class
School grounds, not athletic facilities
School functions (dances, assemblies, etc.)
Extracurricular Programs/facilities/activities at school (clubs, sports teams, etc.)

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* 15. How often did you report when you were harassed or assaulted in school to a teacher, the principal, or other school staff?

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* 16. Overall, how effective was the staff response in addressing the problem the when you reported it?

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* 17. How often have you heard racist comments used in school (such as nigger, spic, wetback, chink, redskin, etc.) used in a negative manner?

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* 18. When racist comments are made and a teacher or other school staff person is present, how often does the teacher or staff member intervene or do something about it?

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* 19. Would you say that racist remarks are made by:

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* 20. How often do you hear racist comments from teachers or school staff?

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* 21. How often do you hear the word "gay" used in a negative way (such as "That's so gay" or "You're so gay") in school?

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* 22. How often have you heard other homophobic remarks used in school (such as "faggot", Dyke", or "queer") used in a negative manner?

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* 23. Would you say homophobic remarks are made by:

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* 24. When homophobic remarks are made and a teacher or other school staff person is present, how often does the teacher or staff person intervene or do something about it?

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* 25. Does your school have a Gay/Straight Alliance or GSA or another club that addresses gay, lesbian, bisexual and transgender students?

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* 26. In general, how accepting do you think students at your school are of LGBTQ perople?

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* 27. What gender were you assigned at birth?

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* 28. Below is a list of terms that people often use to describe their gender.  Please check all that apply to you.

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* 29. What is your race or ethnicity? Check all that apply to you.

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* 30. Is there anything you think we should know about the school culture or any changes to be more inclusive at JFK?

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