Grades 3-5 Safety Survey (Spring 2017)
Think about each question carefully, choose an answer in the box or space that best describes YOU, AT SCHOOL. Please do NOT put your name on this survey.
Where do you go to school?
I am in grade *
This is how safe I feel in each of these places: *
Very Unsafe
A little Unsafe
Mostly Safe
Very Safe
Not Applicable
 in my classroom
on the playground
in the lunch room
on the bus
in the bathroom
in the halls
on a computer or online
How often have these negative events happened to you at school? *
Make a choice for each one
1-2 times per week
1-2 times per month
1-2 times per year
teased in a mean way
called hurtful names
left out of games/activities on purpose
threatened: words or actions that make you feel you may be hurt in some way
hit, kicked or pushed
When I am mistreated or teased, I *
check ALL that apply
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