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* 1. Gender

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* 2. Grade Level

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* 3. Do you feel safe at school?

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* 4. Do you feel safe on your way to school?

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* 5. Do you feel safe on your way home from school?

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* 6. Do other students say things to hurt your feelings?

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* 7. Where are you bullied?

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* 8. Have you ever told your teacher about being bullied?

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* 9. How often does your teacher do something?

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* 10. Do you have any additional comments?

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