Student Questionnaire

Name:
________________________________________________________________________
________________________Gr. & Sec: __________________________
Age: _______________________ Gender: __________________

Please take a few minutes to answer the following questions as honestly and truthfully
as you can. Rest assured that your responses will be confidential. Should you have any
concern after answering the questionnaire, you may approach your guidance counselor
and she will be very much willing to accommodate you.

1) What is your definition of bullying? Please explain.

_____________________________________________________________________
______________________________
_____________________________________________________________________
______________________________

2) Have you ever been a victim of bullying? Check one: ( ) Yes ( ) No

3) If your answer is yes, how were you bullied? Please encircle all that apply to you.

a. Somebody teased you f. A group intimidated or

b. Somebody tried to imitate or scare you scared you
c. Somebody threatened to hurt you g. You were excluded from
d. Somebody stole your things your group
e. A group teased you h. Others
______________________

4) Have you ever been a witness to bullying? Check one: ( ) Yes ( ) No

5) Where does the bullying happen?

_____________________________________________________

6) Would you help someone who is being bullied? Check one: ( ) Yes ( ) No

7) If yes, How?
__________________________________________________________________
______________

If no, Why?
__________________________________________________________________
_______________

8) Do people who are bullied pick on others as well? Check one:

( ) Yes ( ) No

9) Based on your experiences or observations of people around you, how does one
bully? Please encircle all that apply to you

a. Teasing by calling names h. The bully joins a group when

b. Pushing other people around he/she teases
c. Using his/her fists i. By getting what the victim likes
d. By using words most (e.g. bags, ballpen, toys)
e. By hurting others emotionally j. By revealing secrets
 f. By excluding others from a group k. Others:
______________________________
g. Intimidating or scaring others

10) In your opinion, what happens to the person being bullied? Please encircle all
that apply to you.

a. Suffers in school work f. Doesn’t speak to the bully

b. Becomes fearful of the bully g. Avoids the bully
c. Becomes absent from school h. Others:
________________________
d. Bullies others in order to get back
e. Exclude him/herself from friends

11) In your opinion, how does the bullied person feel? Please encircle all that apply
to you.

a. Afraid f. Happy about it

b. Embarrassed g. Enjoys it
c. Angry h. Others: ____________________
d. Uneasy
e. Hates it

12) In your opinion, whom does the bullied person turn to after being bullied?
Please encircle all that apply to you.

a. An older brother or sister

b. Friends from school
c. Friends from home
d. Guidance counselor
e. Assistant to the principal (level coordinator)
f. Classroom adviser
g. Teachers
h. Mother
i. Father
j. Relatives other than parents (e.g. tita, tito, grandparents, cousins)
k. Others:
_______________________________________________________________
______________________

13) In your opinion, where does the bullied person go after being bullied? Please
encircle all that apply to you.

a. Stays at the place where he/she is bullied

b. Runs home
c. Goes to the bathroom
d. Goes to church/chapel
e. Goes to the principal’s office
f. Goes to the assistant principal’s office (Level coordinator’s office)
g. Goes to the faculty room
h. Goes to the guidance counselor’s office
i. Others:
_______________________________________________________________
__________________
14) Are you aware of any school policies on bullying? ( ) Yes ( ) No

15) If yes, what are these policies?

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16) Have you ever been a bully? ( ) Yes ( ) No

17) If yes, what were your reasons for bullying? Please encircle all that apply to you.

a. You wanted to make someone’s life miserable even if they don’t deserve it
b. You wanted to tease that person
c. You wanted to hurt someone
d. You wanted to have fun and some laughter
e. You wanted to be number one among your peer group
f. You wanted attention and popularity
g. You just plainly wanted to do it without any sensible reason
h. Others:
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