If you are under 19 and have ever been bullied, we want to hear from you! Your opinions are important! Responses are confidential. Go here if you have every witnessed someone being bullied. * Required Field
1. If you have ever been bullied, we want to hear from you!
2. Which best describes your current education. *
Kalmiopsis Azalea BHHS BHCS 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 experienced? (check all that apply)
Called names Threatened Teased or made fun of Gossiped about/talk behind your back Something damaged or stolen Shoved, kicked, slapped or hit Ignored Left out on purpose Called “gay” Called “retard”
Other kinds (please specify)
8. Was the person(s) bullying you? (check all that apply)
Bigger than you Older than you Different gender Someone who had been your friend Someone that you did not know at all Maybe jealous of you In the “cool” group
Other types of bullies (please specify)
9. 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 things the bullying was about (please specify)
10. What did you do in response? (check all that apply?)
Nothing Told a friend Told my parents Told an adult at school Bullied them back Ignored it Stayed home Avoided the person bullying Stood up for myself
Other responses (please specify)
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 handle situations differently Support from adults
Other sources? (please specify)
12. Anything else you want to share?
Any other comments?
13. Your zip code? *
Optional information, not required. It will be kept confidential:
Your Name
Your eMail
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