Please answer these questions about your life at school. 


Your age ________                 Grade ________


1. How well do you get along with students at this school? (Circle one of the following.)


 Always well      Usually well      About half the time 


 Usually not well        Never well


We are interested in what bullying goes on in this school.  We call it bullying when people deliberately and repeatedly threaten or hurt a less powerful person by what they do or say.


2. Have you ever been bullied by another student or group this year? (Circle one.)


                                  Yes                              No


3. If you have answered “yes”, indicate how often each of the following has happened to you this year (Circle “never”, “sometimes”, or “often” in each case.)


 I have been hit or threatened.               Never        Sometimes       Often


 I have been called unpleasant names.   Never        Sometimes       Often


 I have been deliberately left out of 

        things by others.                            Never        Sometimes       Often



4. How have you felt about being bullied by others? (Circle one.)


    I was never bullied by anyone.          I was bullied but not bothered by it.


    I was somewhat bothered by it.         I was upset a great deal by it.


5. Do you personally feel safe from being bullied at this school? (Circle your answer.)

                    I always feel safe.      I usually feel safe. 


I feel safe about halftime.         


I usually feel unsafe.                 I never feel safe.


6. Could you use some help to stop the bullying? (Circle your answer.)


     Yes                  Unsure             No



From Ken Rigby’s “STOP The Bullying” A Handbook For Teachers