3-1 Survey - Creating the Survey Draft PDF

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Download 3-1 Survey - Creating the Survey Draft PDF

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Bullying Survey Name: Age: Date of survey: Instructions: Circle one or more that apply to you

1) To which gender identity do you most identify with? Female Male

2) Have you ever felt unsafe at home? Yes No

3) Have you ever thought about suicide or hurting yourself? Yes No

4) What would you do if you see bullying at school? (Circle all that apply) Join in for the fun it Run away Get help or try to stop the bully Nothing, just watch

5) How many times in the past have you been bullied, made fun of by someone or teased by someone? Everyday Sometimes (1 or 2 times a week) Never

6) How were you bullied? (Circle all that apply) Teased and called names Physically hurt Got my stuff taken away Harassed in front of my friends or other students I have not been bullied

7) How many kids have bullied you? (Circle all that apply) A group of kids One to two kids Have not been bullied

8) Why do you think bullies target you? Do not know why Look and act different than others Weaker and smaller than others No one bullies me

9) Why do you think some kids bully others? (Circle all that apply) For fun To impress their friends or want to be popular To take anger out on someone Do not know why

10) What can adults do to help stop bullying at school? (Circle all that apply) Need better supervision at school Talk about bullying in class to prevent it Help students work out their problems Discipline bullies

11) Have you talked to anyone about being bullied at school? (Circle all that apply) Yes, teacher Yes, family or friend No, I have not talked to anyone about it No, I have not been bullied

12) Have your teachers talked to you or your classmates about bullying? Yes, one to two times per month Yes, every week Yes, everyday Not at all

13) Have you ever felt unsafe at school? Yes No

14) Have you ever felt unsafe on your way to school (walking, riding the bus, etc.)? Yes No

15) Have you been bullied? Yes No

16) Has someone pushed you, kicked you, or shoved you on purpose? Yes No 17) Has someone threatened to do physical harm to you? Yes No

18) Has someone threatened you electronically using phones or the internet (Snapchat, Facebook, Twitter, or any other social media)? Yes No

19) Have you ever been made fun of because of your gender? Yes No

20) Have you ever been made fun of because of your race? Yes No

21) Have you ever been made fun of because of your religious beliefs? Yes No

22) Have you ever seen any other children get bullied? Yes No

23) If so, how? (Circle all that apply) Physically Verbally Socially Electronically

24) Have you ever tried to help another kid who was being bullied? Yes No...