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Sample Survey

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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:

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?	Very Unsafe	Kind of Unsafe	So-So	Kind of Safe	Very Safe

How safe do you feel on the playground?	Very Unsafe	Kind of Unsafe	So-So	Kind of Safe	Very Safe

How safe do you feel in the lunch room?	Very Unsafe	Kind of Unsafe	So-So	Kind of Safe	Very Safe

How safe do you feel walking to school?	Very Unsafe	Kind of Unsafe	So-So	Kind of Safe	Very Safe

How safe do you feel in the bathroom?	Very Unsafe	Kind of Unsafe	So-So	Kind of Safe	Very Safe

How safe do you feel in the hall?	Very Unsafe	Kind of Unsafe	So-So	Kind of Safe	Very Safe

How safe do you feel on the bus?	Very Unsafe	Kind of Unsafe	So-So	Kind of Safe	Very Safe

How safe do you feel at the bus stop?	Very Unsafe	Kind of Unsafe	So-So	Kind of Safe	Very Safe

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?	Everyday	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never

How often are you called hurtful names?	Everyday	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never

How often are you left out of things on purpose?	Everyday	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never

How often are you threatened?	Everyday	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never

How often are you hit, kicked or punched?	Everyday	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never

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	Both boys and girls	A group of boys	A boy	A group of girls	A girl	Nobody

At school, who has said mean things to you	Both boys and girls	A group of boys	A boy	A group of girls	A girl	Nobody

At school, who has teased you	Both boys and girls	A group of boys	A boy	A group of girls	A girl	Nobody

At school, who has called you names	Both boys and girls	A group of boys	A boy	A group of girls	A girl	Nobody

At school, who has tried to hurt you at school	Both boys and girls	A group of boys	A boy	A group of girls	A girl	Nobody

We want to know about how bullies work so that we can help you.

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

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

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

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

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?	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 say mean things?	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 tease others?	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 call other children names?	Every day	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never

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?	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 threatened?	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 left out of things on purpose?	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 called hurtful names?	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 hit, kicked, or punched?	Every day	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never

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?	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 on the playground?	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 the lunchroom?	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 walking to or from school?	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 the bathroom?	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 the hall?	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 on the bus?	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 at the bus stop?	Every day	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never

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:

Are you a boy or girl?

Boy

Girl

What is your ethnic group? (optional)

Asian

Black

Hispanic

Native American

White

Where do you go to school?

Elementary School

Middle School

High School

What is your grade in school?

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Liberty Elementary School Guidance Department

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