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Exclusion Survey

Tools

Name (optional):

Grade

Are you a boy or a girl?

boy

girl

My classmates did not allow me to hang around with them.

This happened to me once.

This happened to me several times.

This never happened to me.

I included someone who was alone in an activity.

I did this once.

I did this many times.

I have never done this.

I was left out of an activity.

This happened to me once.

This happened to me several times.

This never happened to me.

I had no friends to talk to.

This happened to me once.

This happened to me several times.

This never happened to me.

I talked to someone who was alone.

I did this once.

I did this many times.

I have never done this.

I noticed that people were nicer to me this week.

True

False

Being left out makes me feel bad about myself.

True

False

I made an effort to include everyone this week.

I did this once.

I did this many times.

I have never done this.

Exclusion is hurtful to others.

True

False

Treating others with kindness makes them feel good about themselves.

True

False

What have you learned about exclusion?

Will this change your behavior? If so, how?