Bully Survey

• Children in grades 2nd through 5th are given the survey

• Tally the surveys for each individual class

• Children are placed on a list if their name appears on the survey 3 or more times

• The staff then discusses the list and puts children into

lunch bunches

• The groups meet weekly and have conversations or activities geared toward bullying behaviors, friendship skills or both

• Some children may meet with a support person (social

worker, psychologist, family liaison) for individual meetings, or be placed in a more structured group

Provided by the Dakota County Attorney’s Office with thanks to Cedar Park Elementary, Apple Valley, MN

BULLY SURVEY

1. I am a: □ girl □ boy Scared and unsafe Kind of safe Very safe

2. In my classroom I feel: □ □ □

3. On the playground I feel: □ □ □

4. In the cafeteria I feel: □ □ □

5. Going to and from school I feel: □ □ □ 6. Other kids hit, kick or push me:

□ every day □ once or twice a week

□ once or twice a year □ never 7. Other kids say mean things to me:

□ every day □ once or twice a week

□ once or twice a year □ never 8. Who has bullied you, said mean things to you, teased you, called you

names, or tried to hurt you at school?

□ boys and girls □ several boys

□ a boy □ several girls

□ a girl □ nobody 9. In what grade is the student or students who bully you?

□ I haven’t been bullied □ in my class

□ in the same grade as me, but in a different class

□ in a lower grade □ in a higher grade

10. If you have been bullied this year, who have you told?

□ my mother or father

□ my sister or brother

□ a teacher or other adult at school

□ another kid at school

□ nobody 11. If you have been bullied this year, who has tried to help you?

□ my mother or father

□ my sister or brother

□ a teacher or other adult at school

□ another kid at school

□ nobody 12. How often do you hit, kick or push other kids?

□ every day

□ once or twice a week

□ once or twice a month

□ once or twice a year

□ never 13. How often do you say mean things, tease or call other kids names?

□ every day

□ once or twice a week

□ once or twice a month

□ once or twice a year

□ never

14. How often do you spend recess alone because nobody wants to play with you?

□ every day

□ once or twice a week

□ once or twice a month

□ once or twice a year

□ never 15. List the three kids in your grade whom you most like to do things with: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 16. List the three kids in your grade whom you don’t like to spend time with: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 17. List the three kids in your grade who you think most need a friend: _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 18. Is there anyone in this class you feel is a bully? _____________________________________________________________ _____________________________________________________________