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1. Please specify your gender.
Male
Female
2. I have observed classmates being bullied at school during the past 12 months.
Agree
Unsure
Disagree
3. If the answer to #1 is Agree, on average, how many times have you observed this
behavior?
Once a day
Several times a day
Once a week
Several times a week
Only a few times in the 12 months
4. I have been the victim of bullying by another student during the 12 months.
Agree
Unsure
Disagree
5. If the answer to #2 is Agree, on average, how many times have you been victimized?
Once a day
Several times a day
Once a week
Several times a week
Only a few times in the past 12 months
6. I have observed one or more of my friends being bullied during the past 12 months.
Agree
Unsure
Disagree
7. The teachers at this school try to reduce bullying.
Agree
Unsure
Disagree
8. The administrators at this school try to reduce bullying.
Agree
Unsure
Disagree
9. The counselors at this school try to reduce bullying.
Agree
Unsure
Disagree
10. If I were bullied at school, I would tell a teacher or other staff member.
Agree
Unsure
Disagree
11. If I were bullied at school, I would tell my parents.
Agree
Unsure
Disagree
12. I believe there is a need for a bullying prevention program at my school.
Agree
Unsure
Disagree
13. Bullying is addressed in the student handbook.
Agree
Unsure
Disagree
14. I believe there is adequate adult supervision of students at school.
Agree
Unsure
Disagree
15. Counselors at my school are involved in bullying prevention
Agree
Unsure
Disagree
16. I believe teachers in this school are consistent and fair in their approach when bullying is observed
or reported.
Agree
Unsure
Disagree
17. I believe the principal or other administrators in this school are fair and consistent in their approach
when bullying is observed or reported.
Agree
Unsure
Disagree
18. I have personally observed students participating in bullying behaviors in the following locations.
Please circle all that apply.
Student Commons/Hallways
Restrooms
Playground/Recess
Classroom
Extracurricular Activities
School Bus
Cafeteria
Locker Rooms
Physical Education Class
On the Way to or From School
19. I have observed classmates being bullied or harassed online.
Agree
Unsure
Disagree
20. If the answer to #16 is Agree, I told (circle all that apply):
No one
Parent
Another Student
A teacher or other adult at school
21. I have been harassed or bullied online.
Agree
Unsure
Disagree
22. If the answer to #17 is Agree, I told (circle all that apply)
No One
Parent
Another Student
A teacher or other adult at school
23. If you have observed bullying at school, or if you have been bullied, please use the space below to
describe what you have seen or experienced. Please be as specific as possible.
24. What suggestions do you have for the prevention of bullying at this school?
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