DIRECTIONS: Please circle or underline the best answers to the following questions. You may have more than one best answer for some questions. You do not have to put your name on the paper.
Name (optional)__________________
1. Have you ever been bullied?
Yes No
• If you answered yes, how often did someone bully you?
Occasionally Often Every day
• Where did it happen?
School Park Home Neighborhood Somewhere else
• If it happened at school, where?
Hallway Classroom Playground Cafeteria Bathroom Somewhere else
2. Have you seen other students being bullied at school?
Yes No
• If you answered yes, how often did it happen?
Occasionally Often Every day
• Where have you seen other students bullied?
Hallway Classroom Playground Cafeteria Bathroom Somewhere else
3. What kinds of things have bullies done to you or to someone you know?
Called names Threatened Stole or damaged something Shoved, kicked, or hit Ignored
4. How much of a problem is bullying for you?
Very much Not much None
5. On the back of this paper, list some of the actions you think parents, teachers, and other adults can do to help children abstain from being bullies and dealing with them.
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