DIRECTIONS:
Think about each question carefully. Put an X in the box that best describes you.
Please do not put your name on this survey.

School: _____________________________ Date: __________________ Grade: _______


1. This is how I feel being at my school:

.	very happy and good
.	sometimes happy and good
.	so-so
.	sometimes sad and unhappy
.	very sad and unhappy

2. This is how safe I feel in each of these places:

..	Very Unsafe	Kind of Unsafe	So-So	Kind of Safe	Very Safe
a) in my classroom	.	..	..	..	..
b) on the playground	.	..	..	..	..
c) in the lunch room	.	..	..	..	..
d) walking to or from school	..	..	..	..	..
e) in the bathroom	.	..	..	..	..
f) in the hall	..	..	..	..	..
g) on the bus	..	..	..	..	..
h) at the bus stop	.	..	..	..	..

3. How often have these things happened to you at school?

Mark all that apply in questions 4 - 8.

4. At school who has:

5. In what grade is the student (or students) who bullies you?

In my classroom	In the same grade but in a different class	In a lower grade	In a higher grade	I haven't been bullied
..	..	..	..	..

6. When I am bullied, I:

..	a) do nothing
..	b) tell the bully to stop
..	c.) get away from the bully
..	d) hurt other kids
..	e) stay home from school
..	f) tell an adult
..	g) tell a friend
..	h) don't get bullied

7. If you have been bullied, who have you told?

..	a) my mother or father
..	b) my sister or brother
..	c) a teacher or another adult at school
..	d) another student at school
..	e) nobody
..	f) I've never been bullied

8. If you have been bullied, who has tried to help you?

..	a) my mother or father
..	b) my sister or brother
..	c) a teacher or another adult at school
..	d) another student at school
..	e) nobody
..	f) I've never been bullied

9. If you have been bullied, what happened after you told someone?

..	a) it got better
..	b) it got worse
..	c) nothing changed
..	d) I never told anyone
..	e) I've never been bullied

10. How often do you hit, kick, or push other children?

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

11. How often do you:

..	Everyday	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never
a) say mean things	..	..	..	..	..
b) tease others	..	..	..	..	..
c) call other children names	..	..	..	..	..

12. How often have you seen someone:

..	Everyday	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never
a) being teased in a mean way	..	..	..	..	..
b) being threatened	..	..	..	..	..
c) left out of things on purpose	..	..	..	..	..
d) being called hurtful names	..	..	..	..	..
e) being hit, kicked, or pushed	..	..	..	..	..

13. How often have you noticed bullying going on in these places?

..	Everyday	1 or 2 times a week	1 or 2 times a month	1 or 2 times a year	Never
a) in my classroom	..	..	..	..	..
b) on the playground	..	..	..	..	..
c) in the lunchroom	..	..	..	..	..
d) walking to or from school	..	..	..	..	..
e) in the bathroom	..	..	..	..	..
f) in the hall	..	..	..	..	..
g) on the bus	..	..	..	..	..
h) at the bus stop	..	..	..	..	..

Mark all that apply in 14-15.

14. Who have you seen doing the bullying?

..	a) both boys and girls
..	b) a group of boys
..	c) a boy
..	d) a group of girls
..	e) a girl
..	f) nobody

15. What grades are the bullies in?

..	a) in my classroom
..	b) in the same grade but in a different class
..	c) in a lower grade
..	d) in a higher grade
..	e. I haven't seen any bullying

16. What is your ethnic group? (optional)

..

Asian

..

Black

..

Hispanic

..

Native American

..

White

17. Are you a boy or a girl?

..

boy

..

girl

Back to Maine Project Against Bully Home Page or Grade 3 Survey Description Page.

Created 8/99.

213078/16/99.