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Bullying Prevention Program Questionnaire
Please answer all questions truthfully so we have accurate data. This questionnaire is completely anonymous.
Helping People. Changing Lives.
1. Are you a: *
2. Choose your grade bracket *
3. I get physically bullied (hit, kicked, punched, pushed around) *
4. I get called names, laughed at, made fun of, or verbally insulted *
5. My friends talk behind my back, spread rumors about me, and/or exclude me from the group *
6. I get sexually harassed at school or community activities *
7. People use the internet, chat rooms, social media, etc. to say hurtful things about me *
8. I bully others *
9. I get bullied, or see bullying happening most often in (check all that apply) *
10. I get bullied, or see it happening (check all that apply) *
11. If someone bullies you, do you (check all that apply) *
12. When you see somebody else being bullied, do you (check all that apply) *
13. If you have been bullied or seen someone bullied, did you report it to the teacher, counselor, administrator or parent/guardian? *
14. How safe do you feel at school? *
OPTIONAL: Without identifying yourself, add any additional comments. (If you need information that requires you to identify yourself, please email us at
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