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
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)
___
___
___ 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.