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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: *
 
 
 
2. Check ONE on each line:
Very UnsafeKind of UnsafeSo-SoKind of SafeVery 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:
Everyday1 or 2 times a week1 or 2 times a month1 or 2 times a yearNever
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 girlsA group of boysA boyA group of girlsA girlNobody
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? *
 
   
6. Check ALL that apply:
When I am bullied, I: *
 
   
7. Check ALL that apply:
If you have been bullied, whom have you told? *
 
   
8. Check ALL that apply:
If you have been bullied, who has tried to help you? *
 
   
9. Check ONE:
If you have been bullied, what happened after you told someone? *
 
   


We want to know if you have seen bullying in your school.
 
 
 
10. Check ONE on each line:
Every day1 or 2 times a week1 or 2 times a month1 or 2 times a yearNever
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 day1 or 2 times a week1 or 2 times a month1 or 2 times a yearNever
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 day1 or 2 times a week1 or 2 times a month1 or 2 times a yearNever
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? *
 
   


Now we need some information about you:
 
   
14. Check ONE:
Are you a boy or girl? *
 
   
15. Check ONE:
What is your ethnic group? (optional)
 
   
16. Check ONE:
Where do you go to school? *
 
   
17. Choose ONE:
What is your grade in school? *
 


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