Who Is A K T Assemblies Keynote Bullies Only Student Session
Take the Bully Survey!
1. Have you ever been physically assaulted or threatened at school?
Yes    No

If yes, please explain
2. Have you ever been in trouble for picking on, bullying or harassing another student?
Yes    No

If yes, please explain
3. Have you ever started or repeated lies about someone at school?
Yes    No

If yes, please explain
4. Have you ever picked on or bullied another student?
Yes    No

If yes, please explain
5. How many times have you missed school because you were afraid of being bullied, harassed or teased?
6. On average, how many incidents of bullying have you witnessed in school this year?
7. Have you ever feared for your personal safety at school?
No    Yes    Seldom    Always

Please explain
8. Where do you think physical violence or bullying is most likely to occur,(i.e. hallways, restrooms, playground, etc.)

Please explain
9. What action would you take or what action do you take when you witness bullying or physical violence?
None    Tell a teacher/staff    Other

Please explain
10. Have you ever bullied someone?
Yes    No    Not sure
11. If you have bullied someone, why?

Please explain
12. Why do you think kids bully?

Please explain
13. Who gets picked on? Why?

Please explain
14. Have you ever talked with an adult about bullying?
Yes    No

Please explain
15. Do you think teachers and staff can prevent bullying/protect the students?
Yes    No    Not Sure

Please explain
16. Have you ever talked with anyone about bullying and physical violence?
Yes    No

Please explain
17. What do you think you can do to prevent or stop bullying and physical violence?

Please explain
18. What can parents do to help stop physical violence or bullying?

Please explain
19. Does your school have an anti bully program? If yes, do you think it is effective?
Yes    No    Don't know

Please explain
20. What do you think the long term results of being bullied are?

Please explain
21. How do you define bullying?

Please explain
22. Where are you from? Country State City Village.

Please explain
23. What grade are you in?
24. What is your age?
25. May we contact you about your story?

Yes      No
26. Your E-mail Address:
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