Bully Prevention Survey

What grade are you in?

Grade 9
Grade 10
Grade 11
Grade 12

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What is your gender?

Male
Female

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Do you feel safe on your way to and from school?

Never
Sometimes
Often
Always

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If you ride a school bus, do you feel safe on the bus?

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If you ride a bus, do you feel safe at the bus drop-off/pick-up area?

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Have YOU been PHYSICALLY bullied by other students in the last three months?

Physical bullying examples: being hit, pushed, shoved, kicked, slapped, had property stolen

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Have YOU been VERBALLY bullied by other students in the last three months?

Verbal bullying examples: called names, teased, insulted, threatened

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Have YOU been SOCIALLY bullied by other students in the last three months?

Social bullying examples: excluded from a group, gossiped about, rumors spread

Option 1

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Have YOU been SOCIALLY bullied by other students in the last three months?

Social bullying examples: excluded from a group, gossiped about, rumors spread

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Have YOU been ELECTRONICALLY bullied by other students in the last three months?

Electronical bullying examples: threatened or embarrassed through e-mail, text message or social networking

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Have YOU been bullied by other students in the last three months because of your GENDER??

Gender bullying examples: left out or treated badly b/c you are a boy or a girl, deragatory comments about you because of your gender, heard sexist comments

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How often have you seen ANOTHER STUDENT being PHYSICALLY bullied in the last 3 months?

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How often have you seen ANOTHER STUDENT being VERBALLY bullied in the last 3 months?

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How often have you seen ANOTHER STUDENT being SOCIALLY bullied in the last 3 months?

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How often have you seen ANOTHER STUDENT being ELECTRONICALLY bullied in the last 3 months?

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How often have you seen ANOTHER STUDENT being bullied in the last 3 months because of his/her GENDER?

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How often have you stayed away from school in order to avoid being bullied since the start of this year?

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How often have you tried to help another student who was being bullied?

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Where and how often does bullying occur?

	Never	Sometimes	Often	Always
Before school
School entrances and exits
Classrooms
Hallways
Library
Computer rooms
Gym
Locker rooms
Bathrooms
School bus
On the way to and from school
Lunchroom/cafeteria
Parking lot
On school field trips/during school extracurricular activities
Off school property, but close to school
On the weekends

Please enter one response per row

What more can teachers and school administrators do to help stop bullying?

(Check the three that most apply.)

Enforce the rules we currently have in place.
Make new rules.
Supervise better.
Teach social skills.
Teach students about bullying and ways to stop it.
Teach teachers about bullying and ways to stop it.
Create a bully report form so students can make reports anonymously.
Make the consequences of bullying more severe.
Other:

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One a scale of 1 to 5, with 1 being NO PROBLEM and 5 being MAJOR PROBLEM, please identify the types of bullying you think are the biggest issues at CHS:

	1 (No problem at all)	2 (Slight problem)	3 (Moderate problem)	4 (Somewhat big problem)	5 (Severe/Major problem)
Physical bullying
Verbal bullying
Social bullying
Electronic bullying
Gender bullying/Sexual harrassment

Please enter one response per row

Use the space below to tell us anything else you'd like us to know.

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Use the space below to tell us what teachers and school administrators can do to make our school safer or a nicer place to be.

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