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Bully Survey

Grades 4-8


A red asterisk (*) indicates required questions.

  1. (Choose one)

    I am a *
    Boy
    Girl



  1. (Choose one)

    My grade is*
    4
    5
    6
    7
    8



  1. (Choose one)

    I have been at CCS *
    since Kindergarten
    since 1st Grade
    since 2nd Grade
    since 3rd Grade
    since 4th Grade
    since 5th Grade
    since 6th Grade
    since 5th Grade
    since 6th Grade
    since 7th Grade



  1. (Choose one)

    I get physically bullied (hit, kicked, pushed or other) at school *
    never
    sometimes (1-3 times per week)
    often (4-6 times per week)
    all the time (7 or more times per week)



  1. (Choose one)

    I get verbally bullied (called names, teased, left out of a group or other) at school*
    never
    sometimes (1-3 times per week)
    often (4-6 times per week)
    all the time (7 or more times per week)



  1. (Choose one)

    I have received mean notes, email, text messages or other communications*
    never
    sometimes (1-3 times per week)
    often (4-6 times per week)
    all the time (7 or more times per week)



  1. Other ways I am bullied include (please describe)


  1. (Choose one)

    I worry about being bullied*
    never
    sometimes (1-3 times per week)
    often (4-6 times per week)
    all the time (7 or more times per week)



  1. (Choose all that apply)

    The bullying happens*
    in the morning in the gym
    in the cafeteria
    on the playground
    in the hallways
    in the bathroom
    in the classroom
    other (please list at number 10)



  1. Other additions to Number 9


  1. (Choose all that apply)

    If someone bullies me, I usually*
    tell the bully to stop
    tell an adult at school
    tell a friend
    tell my parents
    do nothing
    don't get bullied
    other (please list at number 12)



  1. Other additions to number 11


  1. (Choose all that apply)

    If I see someone getting bullied, I usually*
    tell the bully to stop
    tell an adult at school
    tell a friend
    tell my parents
    do nothing
    other (please list at number 14)



  1. Other additions to number 13


  1. (Choose all that apply)

    If I tell an adult about a bully, they usually*
    make the bully stop
    talk to me
    do nothing
    other (please list at number 16)



  1. Other additions to number 15


  1. (Choose all that apply)

    Bullying at school will stop if*
    adults make it stop
    adults are watching
    bullies get in trouble
    my friends help
    other (please list at number 18)



  1. Other additions to number 17


  1. (Choose one)

    I bully others **
    never
    sometimes (1-3 times per week)
    often (4-6 times per week)
    all the time (7 or more times per week)



  1. Please take a moment to tell us about bullying at this school.