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* 1. When I am at school, I feel: (check the boxes that apply)

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* 2. If I do not complete my classwork, it is because: (Check all that apply)

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* 3. Has someone physically threatened, attacked, or hurt you at school?

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* 4. Has someone verbally attacked or threatened you at school?

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* 5. Have you witnessed someone else being bullied at your school?

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* 6. Have you bullied someone at school?

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* 7. When you or someone else was being bullied, what did the bullies do? (Check all that apply)

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* 8. Why do you think you or others have been bullied? (Check all that apply)

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* 9. Check all that apply:

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* 10. I like to come to school at Big Sandy Elementary.

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