King City Union School District - District Office

 What grade are you in?

--- Choose One --- 3rd grade 4th grade 5th grade

 1. What's your gender?

1 - Male   2 - Female  

 2. I am:

1 - Latino/Hispanic/Mexican   2 - Black/African-American   3 - American Indian/Eskimo,Aleut   4 - White/Not of Hispanic Origin   5 - Other  

 3. Students treat each other with respect at my school.

1 - Always   2 - Often   3 - Once in a while   4 - Never  

 4. Students are kind or helpful to students who get teased or are left out.

1 - Always   2 - Often   3 - Once in a while   4 - Never  

 5. Students tell other students to stop doing mean or hurtful things.

1 - Always   2 - Often   3 - Once in a while   4 - Never  

 6. The teachers treat students fairly.

1 - Always   2 - Often   3 - Once in a while   4 - Never  

 7. The Lunch staff and Yard Duty staff treat students fairly.

1 - Always   2 - Often   3 - Once in a while   4 - Never  

 8. The Principals treat students fairly.

1 - Always   2 - Often   3 - Once in a while   4 - Never  

 9. I am happy to be at this school.

1 - Always   2 - Often   3 - Once in a while   4 - Never  

 10. I feel comfortable and get along well with others at this school.

1 - Always   2 - Often   3 - Once in a while   4 - Never  

 11. If feel safe at this school.

1 - Always   2 - Often   3 - Once in a while   4 - Never  

 12. In the past month, how often did you see or experience these things at your school? They could happen to you or to someone else. --- A student teased or made fun of another student in way that hurt his or her feelings.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 13. A student felt left out by another student.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 14. A student was threatened, scared, or harassed by another student.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 15. A student was pushed, hit, or kicked on purpose by another student.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 16. Other students joined in while someone was picking on or bothering someone.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 17. When a student got picked on, other students ignored it instead of helping the student.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 18. Students get “picked on” (teased, left out, bullied, pushed, hit or treated in a mean way) in the classroom.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 19. Students get “picked on” (teased, left out, bullied, pushed, hit or treated in a mean way) on the playground.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 20. Students get “picked on” (teased, left out, bullied, pushed, hit or treated in a mean way) in the lunch area.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 21. Students get “picked on” (teased, left out, bullied, pushed, hit or treated in a mean way) in the bathrooms.

1 - Never   2 - Once in awhile   3 - Often   4 - Always  

 Security Question

Please complete the following: 17 + 4 = *Required

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