Name of School
1. What grade are you in?
2. How old are you?
3. What is your race and/or ethnicity?
4. Are you a boy or a girl?
5. What is your religion?
6. How are your grades in school?
7. Do you like coming to school? If not, why?
8. Are you in any special education classes
9. Is there a "gifted student" program at your school? If so, are you in it?
10. Do you have trouble controlling your emotions or behaviors?
11. Are you involved in extra-curricular activities/teams? Is so, which one(s)?
12. Do you ever worry about not having enough food at home or if your parents can pay all the bills?
13. Do you think your parents care about your grades in school? Do they help you with homework?
14. Are you a member of a gang? If so, which gang? (Remember that all responses are anonymous.)
15. Have you ever used drugs? If so, what did you use? Were you pressured to do it by friends?
16. Have you been bullied in the last year?
17. Have you been bullied in the last 3 year?
18. Have you been bullied in the last 5 years?
19. Have any of your friends been bullied?
20. Have you bullied anyone in the last year?
21. Have you bullied anyone in the last 3 years? 5 years?
22. Do you think that what you want is more important than what other people want and how they feel?
23. Have you ever directly witnessed one students bullying another? If so, what did you do?
24.Have you ever been afraid to speak out against a bully because you did not want him or her to start bullying you?
25. What kind of kids do you think get bullied most?
26. Have you noticed if students with disabilities are bullied more than other kids?
27. What are the reasons girls are bullied here?
28. What are the reasons boys are bullied here?
29. How are kids bullied here? Cyberbullying? Hitting? Teasing? Excluding people?
30. Do you think you will benefit from a Life Experience Day?
31. Do you want to learn how to set and reach goals?
32. Do you think you would benefit from being involved in a weekly lunch and learn?
33. Have you ever been referred to the principal or school counselor? If so, why?
34. Who do you feel most comfortable talking to about bullying? Parents, teachers, school, counselors?
35. Do you ever talk about bullying with your friends?
36. Do you feel like the teaches care about you and want you to learn?
37. What would make you feel more supported by the school? How can they show you that they care about you?
38. What does your school do well?
39. What is something you would change about your school?
40. What can we do for you, as a student?