10-11 CLE Bullying Survey Question Title * 1. Grade 4th 5th Question Title * 2. How do you like school? I like school very much I like school I neither like nor dislike school I dislike school I dislike school very much Question Title * 3. Are you a girl or a boy? Girl Boy Question Title * 4. How many good friends do you have in your classes? I have 6 or more good friends in my class I have 4 or 5 good friends in my class I have 2 or 3 good friends in my class I have 1 good friend in my class None Question Title * 5. Do you know the difference between being bullied and being teased? Yes No Not Sure Question Title * 6. How often have you been bullied at school since the school year began? I haven't been bullied at school since the school year began It has only happened once or twice 2 or 3 times a month About once a week Several times a week Question Title * 7. I was called mean names, was made fun of, or teased in a hurtful way. It hasn't happened to me in the past couple of months. Only once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 8. Other students left me out of things on purpose, excluded me from their group of friends, or completely ignored me. It hasn't happened to me in the past couple of months. Only once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 9. I was hit, kicked, pushed or shoved. It hasn't happened to me in the past couple of months. Only once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 10. Other students told lies or spread false rumors about me and tried to make others dislike me. It hasn't happened to me in the past couple of months. Only once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 11. I had money or other things taken away from me or damaged. It hasn't happened to me in the past couple of months. Only once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 12. I was threatened or forced to do things I didn't want to do. It hasn't happened to me in the past couple of months. Only once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 13. I was bullied with mean names or comments about my race or color. It hasn't happened to me in the past couple of months. Only once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 14. I was bullied with mean names, inappropriate comments, or gestures. It hasn't happened to me in the past couple of months. Only once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 15. Have you been bullied by boys or girls? I haven't been bullied at school in the past couple of months. Mainly by 1 girl By several girls Mainly by 1 boy By several boys By both girls and boys. Question Title * 16. By how many students have you usually been bullied? I haven't been bullied at school in the past couple of months Mainly by 1 student By a group of 2 - 3 students By a group of 4 - 9 students By a group of more than 9 students By several different students or groups of students Question Title * 17. How long has the bullying lasted? I haven't been bullied at school in the past couple of months It lasted one or two weeks or less It lasted about a month It has lasted about 6 months It has lasted about a year It has gone on for several years Question Title * 18. Where have you been bullied (check as many choices as you need to)? On the playground/field In the hallways In class with the teacher present In class with the teacher out of the room In the bathroom In gym class In the lunch room On the way to and from school At the school bus stop On the school bus Somewhere else in school In this case, please tell us where Question Title * 19. Have you told anyone that you have been bullied at school in the past couple of months? I haven't been bullied in the past couple of months I have been bullied but have not told anyone I have been bullied and have told someone about it. Question Title * 20. If you have told somone you have been bullied, please tell us who you told (check as many choices as you need to): Your homebase teacher The Principal or Assistant Principal Another adult at school Your parents or guardians Your brothers or sisters Your friends somebody else Please tell us who Question Title * 21. How often do the teachers or other adults at school try to put a stop to it when a student is being bullied at school? Almost never Once in a while Sometimes Often Almost always Question Title * 22. How often do other students try to put a stop to it when a student is being bullied at school? Almost never Once in a while Sometimes Often Almost always Question Title * 23. Has any adult at home contacted the school to try to stop you being bullied at school in the past couple of months? I haven't been bullied at school in the past couple of months No, they haven't contacted the school Yes, they have contacted the school Yes, they have contacted the school several times. Question Title * 24. When you see a student your age being bullied at school, what do you feel or think? That it is probably what he or she deserves. I don't feel much. I feel a bit sorry for him or her. I feel sorry for him or her and want to help him or her. Question Title * 25. How often have you taken part in bullying another student at school in the past couple of months? I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 26. I called another student(s) mean names, made fun of or teased him or her in a hurtful way. I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 27. I kept him or her out of things on purpose, excluded him or her from my group of friends or completely ignored him or her. I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 28. I hit, kicked, pushed and shoved him or her. I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 29. I spread false rumors about him or her and tried to make others dislike him or her. I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 30. I took money or other things from him or her or damaged his or her belongings. I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 31. I threatened or forced him or her to do things he or she did not want to do. I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 32. I bullied him or her with mean names or comments about his or her race or color. I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 33. I bullied him or her with mean names, inappropriate comments or gestures. I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. Question Title * 34. I bullied him or her in another way. I haven't bullied another student(s) at school in the past couple of months. It has only happened once or twice. 2 or 3 times. About once a week. Several times a week. In this case, please write the way: Question Title * 35. Has your homebase teacher or any other teacher talked with you about your bullying other students at school in the past couple of months? I haven't bullied another student(s) at school in the past couple of months. No, they have not talked with me. Yes, they have talked with me once. Yes, they have talked with me several times. Question Title * 36. Has any adult at home talked with you about your bullying other students at school in the past couple of months? I haven't bullied other student(s) at school in the past couple of months No, they have not talked with me about it. Yes, they have talked with me about it once Yes, they have talked with me about it several times. Question Title * 37. Do you think that you could join in bullying a student whom you did not like? Yes, Yes, maybe I don't know No, I don't think so No Definitely no Question Title * 38. How do you usually react if you see or understand that a student your age is being bullied by other students? I have never noticed that students my age have been bullied I take part in the bullying I don't do anything, but I think the bullying is OK I just watch what goes on I don't do anything, but think I ought to help the bullied student. I try to help the bullied student in one way or another. Question Title * 39. How often are you afraid of being bullied by other students in your school? Never Seldom Sometimes Fairly Often Often Very often Done >>