Dr. Martin Luther King Jr. School Complex
Bullying Survey

Use the pull down menu in front of each question to select the best answer for each item.

Select One 3rd 4th 5th   Which grade are you in? 

Select One Boy Girl   Are you a boy or girl   

Select One Yes No   Do you think there are bullies in your school?

Select One No problem at all A little problem A big problem   How much of a problem is bullying in your school?

Select One Yes No   Have you ever been bullied?   

Select One Yes No   How often have you been bullied?

If you have been bullied, did you ever tell:
Select One Yes No   A friend? 
Select One Yes No   An adult (counselor, minister, or other grown-up)?
Select One Yes No   Your parent or guardian?  
Select One Yes No   A teacher?

Select One Yes No   If you told someone that you were being bullied, did that person help you?

Select One Every Day Once a week Not very often Not at all   How often have you had teased?  

Select One Every Day Once a week Not very often Not at all   How often have people spreading rumors about you? 

Select One Every Day Once a week Not very often Not at all   How often have you been left out of a group?  

Select One Every Day Once a week Not very often Not at all   How often have people shouted at you? 

Select One Every Day Once a week Not very often Not at all   How often have you been threatened? 

Select One Every Day Once a week Not very often Not at all   How often have you been hit?

Select One Every Day Once a week Not very often Not at all   How often have you been kicked? 

Select One Every Day Once a week Not very often Not at all   How often have by been instigated to do things? 

Select One Every Day Once a week Not very often Not at all   How often have people taken thing from you? 

Select One Yes No   Have you ever been absent because you were being bullied? 

Select One Yes No   Have you ever fought back against a bully?

Who can be a bully?
Select One Yes No    A girl?
Select One Yes No    A boy? 
Select One Yes No    A teacher? 
Select One Yes No    A parent or guardian?
Select One Yes No    A relative?

Select One Yes No   Do you think you are a bully?