* 1. Gender

* 2. Grade Level

* 3. Do you feel safe at school?

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

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

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

* 7. Where are you bullied?

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

* 9. How often does your teacher do something?

* 10. Do you have any additional comments?

T