* 1. I am a

* 2. I am in grade:

* 3. In my classroom I feel:

* 4. On the playground I feel

* 5. In the cafeteria I feel:

* 6. Going to and from school I feel:

* 7. Playing at home in my neighborhood I feel:

* 8. Other kids hit, kick or push me:

* 9. On social media like messenger and musically other kids say mean things to me:

* 10. Other kids say mean things to me:

* 11. I use social media (snap chat, musically, messenger)

* 12. Other kids say nice things to me or help me:

* 13. Who has bullied you, said mean things to you, teased you, called you names, or tried to hurt you at school?

* 14. In what grade is the student or students who bully you?

* 15. If you have been bullied this year, who have you told?

* 16. If you have been bullied this year, who has tried to help you?

* 17. How often do you hit, kick or push other kids?

* 18. How often do you say mean things, tease or call other kids names?

* 19. How often do you spend recess alone because nobody wants to play with you?

* 20. List the three kids in your grade whom you most like to do things with:

* 21. List the three kids in your grade whom you don’t like to spend time with:

* 22. List the three kids in your grade who you think most need a friend:

* 23. Is there anyone you feel is a bully?

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