I am a

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* 1. I am a

I am in grade:

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* 2. I am in grade:

In my classroom I feel:

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* 3. In my classroom I feel:

On the playground I feel

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* 4. On the playground I feel

In the cafeteria I feel:

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* 5. In the cafeteria I feel:

Going to and from school I feel:

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* 6. Going to and from school I feel:

Playing at home in my neighborhood I feel:

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

Other kids hit, kick or push me:

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

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

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

Other kids say mean things to me:

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* 10. Other kids say mean things to me:

I use social media (snap chat, musically, messenger)

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

Other kids say nice things to me or help me:

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

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

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

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

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

If you have been bullied this year, who have you told?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Is there anyone you feel is a bully?

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

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