_______________HIGH SCHOOL SURVEY

 

Please answer this survey as honestly as possible.  Your answers are confidential and anonymous.  Mark your answers on the scantron.  If there is only one answer per question,  use answer A on the scantron to record your answer. 

 

Last school year, (2008-2009: August 2008 to June 2009), how many times on school property during those 9 months have you:

 

                                       Scantron:    A           B           C              D                  E

1. been pushed, shoved, hit, slapped or kicked by someone who wasn’t joking around:

0 times   1 time     2 times      3 times        4 or more times

2. been afraid of being beaten up

0 times   1 time     2 times      3 times        4 or more times

3. been in a physical fight

0 times   1 time     2 times      3 times        4 or more times

4. had mean rumors or lies spread about you

0 times   1 time     2 times      3 times        4 or more times

5. had sexual jokes, comments or gestures made to you

0 times   1 time     2 times      3 times        4 or more times

6. been made fun of because of your looks or the way you talk

0 times   1 time     2 times      3 times        4 or more times

7. had your property stolen or deliberately damaged

0 times   1 time     2 times      3 times        4 or more times

8. not felt safe (physically or emotionally) at school

0 times   1 time     2 times      3 times        4 or more times

9. felt or been isolated by your peers

0 times   1 time     2 times      3 times        4 or more times

 

Last school year  (2008-2009: August 2008 to June 2009), how many times on school property during those 9 months have you witnessed someone else:

 

                                    Scantron:    A           B           C              D                  E

10. be pushed, shoved, hit, slapped or kicked by someone who wasn’t joking around:

0 times   1 time     2 times      3 times        4 or more times

11. be in a physical fight

0 times   1 time     2 times      3 times        4 or more times

12. spread mean rumors or lies about another person

0 times   1 time     2 times      3 times        4 or more times

13. make sexual jokes, comments or gestures about another person

0 times   1 time     2 times      3 times        4 or more times

14. be made fun of because of his or her looks or the way they talk

0 times   1 time     2 times      3 times        4 or more times

15. have their property stolen or deliberately damaged

0 times   1 time     2 times      3 times        4 or more times

16. intentionally isolate another student

0 times   1 time     2 times      3 times        4 or more times

 

 

If you saw someone else being victimized in the section above, what, if anything did you do?  (Answer Scantron A for all that apply)

17. _____  I did nothing

18. _____  I told the person to stop.

19. _____  I told an adult

20. _____  I helped the victim

21. _____  I participated in the act

 

Last school year (2008-2009: August 2008 to June 2009), how many times on school property during those 9 months have you been harassed, teased, called names or bullied for any of the following reasons:

                                  Scantron:       A           B           C              D                  E

22. Your race, ethnicity or national origin

0 times   1 time     2 times      3 times        4 or more times

23. Your religion

0 times   1 time     2 times      3 times        4 or more times

24. Your gender (being male or female)

 

25. Because you were gay or lesbian or someone thought you were

0 times   1 time     2 times      3 times        4 or more times

26. A physical or mental disability

0 times   1 time     2 times      3 times        4 or more times

Any other reason

0 times   1 time     2 times      3 times        4 or more times

 

If you were personally harassed, teased, called names or bullied for any of the above reasons, what, if anything did you do?  (Answer Scantron A for all that apply)

27. _____  I did nothing

28. _____  I told the harasser/teaser/bully to stop.

29. _____  I told a teacher/school administer

30. _____  I told a friend

31. _____  I told my parents

 

If you did nothing, why? (Answer Scantron A for all that apply)

32. _____  I was too afraid

33. _____  I feared retaliation

34. _____  I was afraid if I told, the adult would tell the bully/harasser

35. _____  I didn’t think anyone would believe me

36. _____  I didn’t think telling would change anything

37. _____  It is worse to be a “snitch”

 

If you told a teacher or school administrator, what was the result?  (Answer Scantron A for all that apply)

38. ____  I was not believed

39. ____  An investigation was conducted

40. ____  A peer-mediation occurred

41. ____  Discipline was given

42. ____ Nothing changed

43. ____  I don’t know

Last school year (2008-2009 school year: August 2008 to June 2009), how many times on school property during those 9 months have you seen someone else be harassed, teased, called names or bullied for any of the following reason:

                                   Scantron:        A           B           C              D                  E

44. Their race, ethnicity or national origin

0 times   1 time     2 times      3 times        4 or more times

45. Their religion

0 times   1 time     2 times      3 times        4 or more times

46. Their gender (being male or female)

0 times   1 time     2 times      3 times        4 or more times

47. Because they were gay or lesbian or someone thought so

0 times   1 time     2 times      3 times        4 or more times

48. A physical or mental disability

0 times   1 time     2 times      3 times        4 or more times

49. Any other reason

0 times   1 time     2 times      3 times        4 or more times

 

If you saw someone else being harassed, teased, called names or bullied for any of the above reasons what, if anything did you do?  (Answer Scantron A for all that apply)

 

50. _____  I did nothing

51. _____  I told the harasser/teaser/bully to stop.

52. _____  I told an adult

53. _____  I helped the victim

54. _____  I participated in the teasing/bullying/harassing behavior

 

Do you think ______________ School District is doing enough to stop bullying, harassment and namecalling on its campuses?  (Answer Scantron A for the applicable answer)      55. ____ Yes                  56. ____  No

 

Please mark each of the following that applies to you? (Answer Scantron A for each that applies)

 

57. ___   African American     58.  ___ Latino/Hispanic        59.  ____  Asian      

60. ____ Caucasian                  61. ___  Jewish                       62. ___  Muslim                       63. ____ Christian                    64. ___  Gay/Lesbian              65. ___ Special Ed Student     66. ____ COSA student   

  

My gender:                  67.___ male (Scantron A)       ___   female (Scantron B)

 

68:  Last year I went to school at: (Check one)

 

            ___  _________ High School           (Scantron A)

            ___  ____________ Middle School (Scantron B)

            ___  OTHER                                     (Scantron C)

 

My current grade:  (Answer Scantron A for the question that is applicable)

69.____ 9th                      70.___10th                  71.___ 11th               72.___12th

Letter requesting No Name Calling Week Adoption

I am writing you on behalf of VACHI (Voices Against Cruelty, Hatred and Intolerance).  [insert date] is National “No Name Calling Week”. VACHI is hopeful that you would issue a proclamation of some sort declaring [insert date] “No Name Calling Week” in [insert name of town/school]. 

  No Name-Calling Week was inspired by the book "The Misfits" by James Howe.[1] The book tells the story of a group of friends trying to survive the seventh grade in the face of taunts based on their weight, height, intelligence, and sexual orientation. Seeking to inspire change, the "Gang of Five" (as they are known) creates a new political party during student council elections and run on a platform aimed at wiping out name-calling of all kinds. Though they lose the election, they gain the support of the school's principal for their cause and their idea for a "No Name-Calling Day" at school.

           Motivated by this book, a group of 40 National organizations have supported the creation of a National No Name Calling Week. This year, No Name-Calling Week will take place the week of [insert date]. The “No Name Calling Week” website explains that the “project seeks to focus national attention on the problem of name-calling in schools, and to provide students and educators with the tools and inspiration to launch an on-going dialogue about ways to eliminate name-calling in their communities.” Here is a link to the website that will tell you more about it:

http://www.nonamecallingweek.org/cgi-bin/iowa/all/about/index.html

           Please let me know whether you will help us with this important mission. 

 



[1] All information is from the No Name Calling Website