Appendix F Questionnaire about School Safety

This questionnaire is designed to give parents a chance to speak on issues facing students in schools. This is an anonymous questionnaire. If
you choose to complete the survey, you don’t have to let us know who you are. You are also welcome to complete this questionnaire online
(URL). Since we are looking at issues at schools across the district, please provide the following information regarding the child(ren) who
attends (insert name of school).

Current Grade Gender Diagnosed with Is

School
Disability?
Generally, a Safe

Environment?

Child 1 M F Yes No Yes No

Child 2 M F Yes No Yes No

Please identify what you believe is the major safety concern for your child at his/her school:_____________
_____________________________________________________________________________________

Now we’d like to ask you about some general safety issues that students might encounter from other people at school such as bullying and
harassment.

Bullying is when a student or students hurt someone. For example, when students say mean and hurtful things; ignore or exclude students; hit,
kick, push, shove others around, spread rumors about someone, or send mean notes, try to make other students dislike someone; or use a
computer or cell phone to do these things, etc. Bullying is when these things happen repeatedly, and it is difficult for the student being bullied to
defend against it or make the other person stop. But we don't call it bullying when the teasing is done in a friendly and playful way and it does
not bother the other person. Also, it is not bullying when two students of about equal strength or power argue or fight. Please use this definition
to answer the next question.

Never 1. Only once or twice 2. 2 or 3 times a month 3. About once a week 4. Several times a week

5. 6. 7. 8.

1. During this current year at school, how often have each of your children been bullied? (Write in the corresponding number of the
child in the correct box, ex. If child 2 has never been bullied, write in “2” in the box under “Never.”)
(If you answered never, skip to question 7)

2.

During this school year, your child(ren) has been bullied/harassed in the Write in the number of each
following ways: child who experienced each
of the following:

− Called mean names, was made fun of, or teased in a hurtful way

− Left out of things on purpose, excluded or ignored

− Hit, kicked, pushed, shoved around, or locked indoors

− Lied or spread false rumors about him/her

− Had money or other things taken away or damaged

− Was threatened or forced to do things he/she didn't want to do

− Called mean names about his/her race or color

− Called mean names with a gender or sexual meaning

− Called mean names related to sexuality or sexual orientation

− Called mean names related to how he/she looks or walks, e.g., “cripple”, “retard,” “gimp,”
etc.

− Called mean names related to how he/she learns or speaks, e.g., “stupid,”
“retard,” “slow,” etc.

− Received a phone call, text or pix message(s) with mean names, comments or
threats about him/her

− Received an email(s) and/or instant message(s)(IM) with mean names, comments

or threats

− Mean comments or threats directed toward him/her were put on a website by

other students

− Anything else (write in here)

3.

Which strategies for handling a bullying/harassing situation would you recommend to your
child? (Mark All That Apply)

− Just take it

− Walk away

− Ignore the bully

− Hit or fight back

− Tell the bully to stop

− Tell me or another family member

− Tell a teacher or other staff member

− Get help from friends

− Anything else (write in here)

4. How did you find out your child (ren) was being bullied/harassed? (Circle first informant)
My child Class teacher Staff at school Friend/sibling of child Other_________
5. Did the school respond? (Circle one of the following): Yes No
Please identify what they did. If you don’t know what occurred, please identify that.
________________________________________________________________________________
________________________________________________________________________________
6. Do you feel the school could have done more? (Circle one of the following): Yes No
Please explain what else could have been done: __________________________________________
________________________________________________________________________________
7. Has anyone at the school ever informed you that your child(ren) is a bully? Yes No
8. Have you spoken to your child(ren) about not being a bully? Yes No
Thank you for taking the time to answer these questions. Now, please tell us a little about yourself.
9. Gender: (Circle one of the following): Male Female
10. Ethnicity (Please circle all that apply): African American Asian Hispanic Caucasian/Non-Hispanic Native American/Pacific
Islander Other_________
11. Please circle the relevant age range for yourself: 18-30 years 31-40 years 41-50 years
51- 60 years 61 or older
12. Have you ever attended a training session or workshop on bullying? Yes No

Thank You for Participating!