If you are under 19 and have ever seen bullying? If so, we want to hear from you! Your opinions are important! Responses are confidential. Go here if you have every been bullied. * Required Field
1. If you have ever seen bullying, we want to hear from you!
2. Which best describes your current education. *
Kalmiopsis Elementary School Azalea Middle School Brookings-Harbor High School Brookings-Harbor Christian School Homeschool Other (please specify)
3. Does your school have a bullying prevention program?
Yes No
4. Are you a? *
Boy Girl
5. What grade are you in? *
6. Where did the bullying occur? (check all that apply)
Hallway Classroom Locker room Cafeteria Bathroom Bus Cell phone Internet
Other places (please specify)
7. What kind of bullying have you seen? (check all that apply)
Name calling Threats Tease or making fun of Gossiped, talking behind back Something damaged or stolen Shoved, kicked, slapped or hit Ignored Left out on purpose Calling someone “gay” Calling someone a “retard”
Other ways (please specify)
8. Was the bullying about any of the following? (check all that apply)
Academic ability Age Clothing Disability Family income Gender/sexual orientation Hair Height Race Religion Sports Ability Weight Where they live
Other issues (please specify)
9. What did you do in response? (check all that apply)
Joined in, bullied too Nothing. It's not my problem Wanted to do something but afraid to get involved Felt bad for other person, but didn't do anything Laughed along with everyone else Told the person bullying to stop Let an adult know what was happening Helped the person being bullied Talked with parents about it Talked with a friend about what happened
Other responses (please specify)
10. Would you have liked to have done more?
11. What would help you to address bullying? (check all that apply)
More information about what you do in bullying situations Bullying policies posted at school Support from other students Education for kids who bully, how they can do handle situations differently Support from adults
Other resources (please specify)
12. Anything else you want to share?
Anything else?
13. Your zip code? *
Optional information, not required. It will be kept confidential:
Your Name
Your eMail
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