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Q.1
During this school year, how many times, if any, has someone made fun of you, called you names, or insulted you?

Q.2
During this school year, how many times, if any, has someone spread rumors about you?

Q.3
During this school year, how many times, if any, has someone pushed you, shoved you, tripped you, or spit on you?

Q.4
During this school year, how many times, if any, has someone threatened you with harm?

Q.5
During this school year, how many times, if any, has someone destroyed your property on purpose?

Q.6
Do you have a bullying occurrence you want to share? (do not use names)

Q.7
During this school year, how many times, if any, has someone left you out of or wouldn't let you join in activities on purpose?

Q.8
During this school year, how many times, if any, has someone used cell phones or the Internet to say or post hurtful things about you?

Q.9
Which school do you attend?

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