WELCOME TEENS!

Please take a few minutes to fill out our survey (answer all questions, if they don't apply put N/A in the box). The results will better help us to stop bullying and offer the help and healing that is needed. Also let us know if you think of a question or topic that needs to be addressed. Thank you for your time and cooperation in this urgent matter!

Together we can Change Hearts & Save Lives!

E-mail Address: *
What grade are you in? *
What city and state are you from? *
What school do you attend? *
What is your homeroom teachers name? *
Are you male or female? *	male female
What is your race?	White/Caucasian African American Latino Mixed Other
Do you consider yourself lesbian/gay?	yes no
Have you ever been bullied or abused? *	yes no
Have you been bullied or abused this year? *	yes no
Where have you been bullied? *	Online/Cyber School Playground Bus Texting or Sexting Lunch room Bathroom Classroom Off Campus
In what ways have you been bullied/abused? *	Verbal Physical Sexual Emotional Cyber Text Physical Dating Violence Life Threatened
When you were bullied did you... *	Fight Back Report It Keep It a Secret Run Away
What happened to the person who bullied you? *	Nothing Parents Called Warning Detention 3-5 Day Suspension Expelled Grounded Probation Still Bullies You Stopped Bullying You Youre Friends
Have you ever bullied or abused anyone? *
Have you bullied or abused anyone this school year? *
Where did you bully them? *	Online/Cyber Bus Playground Lunch room Classroom Bathroom Gym Off Campus
In what ways did you bully others? *	Verbal Physical Emotional Cyber Sexual Text Threatened Dating Violence Peer Pressure
Why did you bully/abuse others? *	Peer Pressure To Get Friends For Power & Control Fear--Hurt Yourself Revenge
What happened as a result of you bullying others?	Nothing Parents Called Grounded Warning Probation Detention 3-5 Day Suspension Kept Bullying Felt Bad Stopped Bullying Told Victim You Were Sorry Expelled
What do you see as the biggest form of bullying today? *	Cyber Text Emotional Physical Verbal Sexual Threats Peer Pressure Self Abuse
Have you ever thought of hurting or killing yourself? *
Have you ever abused/bullied yourself? *
In What Ways did you abuse/bully yourself? *	Drugs or Alcohol Cutting/ Physical Harm Bad Relationships/ Dating Violence/ Peer Pressure Poor Self Image Eating Disorders/ Anorexia or Bulimia
Have you ever thought of hurting or killing others? *	yes no
Have you ever been afraid of going to school because you didnt feel safe? *
Does your school have an anti-bullying policy in place that you are aware of? *
Does your school have a Bully Buster program or anti-bullying program for students to get involved in? *
Would you like to be part of a Bully Buster Program if they had one? *
Do you think it would be helpful for everyone in your school to sign our Abuse Bites Bully Buster Pledge? *
What was your favorite part of our program?
How did our program help you? It Taught me.. *
What was the biggest thing you learned that you didnt already know? *
Before our program what was your main role? *	Bully Bystander Victim Bully Buster
What is your main role now after going through our program? *	Bully Buster Bully Victim Bystander


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