Have you been bullied?

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

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”

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

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

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

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 

12. Anything else you want to share?

 

13. Your zip code? *

Optional information, not required. It will be kept confidential:

Your Name

Your eMail

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 ©2013, Gordon Clay