Name of School
1. What grade are you in, and how old are you?
2. With what race or ethnicity do you identify?
3. Are you male or female?
4. Do you feel like your biological sex matches your gender identity?
5. Do you identify as a member of the LGBTQIA+ community?
6. What is your religion?
7. How are your grades in school?
8. Do you like coming to school? If not, why?
9. Are you in any form of special education?
10. Are you considered a gifted student?
11. Do you have problems controlling your emotions or behaviors?
12. Are you involved in extra-curricular activities?
13. What is your family's financial status? Do you ever worry about your family not having enough food or money?
14. How involved are your parents in your school and education?
15. Are you a member of a gang? If so, which gang? (Remember that all responses are anonymous.)
16. Do you use any illegal drugs, including marijuana and alcohol? (Since you are under 21, both are still illegal for your use no matter if the use of these is legal in your state after the age of 21.) If you use drugs, what do you use and how often?
17. Have you been bullied in the last year?
18. Have you been bullied in the last 3 years?
19. Have you been bullied in the last 5 years
20. Have any of your friends been bullied?
21. Have you bullied anyone in the last year?
22. Have you bullied anyone in the last 3 years? 5 years?
23. Do you think that your rights, needs, and wants are more important than the rights of those around you?
24. Do you think your feelings matter more than other people's feelings?
25. Have you ever directly witnessed one student bullying another? If so, what did you do?
26. Have you ever been afraid to speak out against a bully because you did not want him or her to start bullying you?
27. Who do you think are the most common targets of bullying?
28. Have you notice if students with disabilities are unfairly targeted as bullying victims?
29. What are the reasons females are bullied here?
30. What are the reasons males are bullied here?
31. What methods of bullying are most frequently used? Cyberbullying? Teasing? Excluding people?
32. Do you think you will benefit from a Life Experience Day?
33. Do you want to learn leadership skills and work toward setting and accomplishing goals?
34. Do you think you would benefit from being involved in the weekly Lunch and Learn?
35. Have you ever been referred to the principal or school counselor? If so, why?
36. Do you feel comfortable discussing issues of bullying with your parents, teachers, counselors, or other staff members? If so, with whom do you feel most comfortable talking about this issue?
37. Do you ever talk about bullying with your friends?
38. Do you feel supported by the faculty and staff at this school?
39. What would make you feel more supported by the school?
40. What is something that you feel that the school does well?
41. What is something you would change about this school if you had the power?
42. What can we do to support you as a student?