Sample Survey

Sample Survey


   
 

Liberty Elementary School Guidance Department


Bullying Survey


Maye & Panich (2005)

Directions: Think about each question carefully. Click each circle or box that best describes YOU.


 
   

We want to know how you feel about your school and how safe you feel:
 
   
1. Check ONE:
This is how I feel about being at my school: *
 
Very happy and good
 
Sometimes happy and good
 
So-so
 
Sometimes sad and unhappy
 
Very sad and unhappy
 
 
 
2. Check ONE on each line:
Very Unsafe Kind of Unsafe So-So Kind of Safe Very Safe
How safe do you feel in your classroom?
How safe do you feel on the playground?
How safe do you feel in the lunch room?
How safe do you feel walking to school?
How safe do you feel in the bathroom?
How safe do you feel in the hall?
How safe do you feel on the bus?
How safe do you feel at the bus stop?
 
 
 
3. Check ONE on each line:
Everyday 1 or 2 times a week 1 or 2 times a month 1 or 2 times a year Never
How often are you teased in a mean way? *
How often are you called hurtful names? *
How often are you left out of things on purpose? *
How often are you threatened? *
How often are you hit, kicked or punched? *
 
 
 
4. Check ALL answers that apply:
Both boys and girls A group of boys A boy A group of girls A girl Nobody
At school, who has bullied you *
At school, who has said mean things to you *
At school, who has teased you *
At school, who has called you names *
At school, who has tried to hurt you at school *
 
   

We want to know about how bullies work so that we can help you.
 
   
5. Check ALL that apply:
In what grade is the student (or students) who bullies you? *
 
In my classroom
 
In the same grade, but different class
 
In a lower grade
 
In a higher grade
 
I haven't been bullied

 
   
6. Check ALL that apply:
When I am bullied, I: *
 
Do nothing
 
Tell the bully to stop
 
Get away from the bully
 
Hurt other kids
 
Stay home from school
 
Tell an adult
 
Tell a friend
 
I don't get bullied

 
   
7. Check ALL that apply:
If you have been bullied, whom have you told? *
 
My mother or father
 
My sister or brother
 
A teacher or other adult at school
 
Another student at school
 
Nobody
 
I don't get bullied

 
   
8. Check ALL that apply:
If you have been bullied, who has tried to help you? *
 
My mother or father
 
My sister or brother
 
A teacher or other adult at school
 
Another student at school
 
Nobody
 
I don't get bullied

 
   
9. Check ONE:
If you have been bullied, what happened after you told someone? *
 
It got better
 
It got worse
 
Nothing changed
 
I never told anyone
 
I don't get bullied
 
   

We want to know if you have seen bullying in your school.
 
 
 
10. Check ONE on each line:
Every day 1 or 2 times a week 1 or 2 times a month 1 or 2 times a year Never
How often do you hit, kick, or push other children? *
How often do you say mean things? *
How often do you tease others? *
How often do you call other children names? *
 
 
 
11. Check ONE on each line:
Every day 1 or 2 times a week 1 or 2 times a month 1 or 2 times a year Never
How often have you seen someone being teased in a mean way? *
How often have you seen someone being threatened? *
How often have you seen someone left out of things on purpose? *
How often have you seen someone being called hurtful names? *
How often have you seen someone being hit, kicked, or punched? *
 
 
 
12. Check ONE on each line:
Every day 1 or 2 times a week 1 or 2 times a month 1 or 2 times a year Never
How often have you seen bullying in your classroom? *
How often have you seen bullying on the playground? *
How often have you seen bullying in the lunchroom? *
How often have you seen bullying walking to or from school? *
How often have you seen bullying in the bathroom? *
How often have you seen bullying in the hall? *
How often have you seen bullying on the bus? *
How often have you seen bullying at the bus stop? *
 
   
13. Check ALL that apply:
Who have you seen doing the bullying? *
 
Both boys and girls
 
A groups of boys
 
A boy
 
A group of girls
 
A girl
 
Nobody

 
   

Now we need some information about you:
 
   
14. Check ONE:
Are you a boy or girl? *
 
Boy
 
Girl
 
   
15. Check ONE:
What is your ethnic group? (optional)
 
Asian
 
Black
 
Hispanic
 
Native American
 
White
 
   
16. Check ONE:
Where do you go to school? *
 
Elementary School
 
Middle School
 
High School
 
   
17. Choose ONE:
What is your grade in school? *