Please check one:
Male ___
Female ___
What grade are you in? _____________________
In the past year:
Has someone made unwelcome sexual comments, jokes or gestures to or about you in person?
No ___ Yes, but only once ___ Yes, and it has happened more than once: ___
Has someone made unwelcome sexual comments, jokes or gestures to or about you online?
No ___ Yes, but only once ___ Yes, and it has happened more than once: ___
Have you been called gay or lesbian in a negative way?
No ___ Yes, but only once ___ Yes, and it has happened more than once: ___
Have you been shown sexual pictures that you did not want to see?
No ___ Yes, but only once ___ Yes, and it has happened more than once: ___
Have you been touched in an unwelcome sexual way?
No ___ Yes, but only once ___ Yes, and it has happened more than once: ___
Have you been physically intimidated in a sexual way?
No ___ Yes, but only once ___ Yes, and it has happened more than once: ___
Has someone flashed or exposed themselves to you?
No ___ Yes, but only once ___ Yes, and it has happened more than once: ___
Have you been forced to do something sexual?
No ___ Yes, but only once ___ Yes, and it has happened more than once: ___
If you answered “yes….” to any of the previous questions:
Have you ever wanted to skip school to avoid harassment?
No ___ Yes ____
Have you ever had trouble sleeping because of harassment?
No ___ Yes ____
Have you ever felt sick to your stomach from harassment?
No ___ Yes ____
Did you do anything about the harassment?
No ___
Yes ___
If “yes”:
Did you tell a school official?
No ___ Yes ____
Did you tell a friend?
No ___ Yes ____
Did you tell a family member?
No ___ Yes ____
Free response:
1) What kind of student has the highest risk of being harassed?
2) What kind of student has the least risk of being harassed?
3) Why do you think that students harass each other?
4) What do you think schools can do to help stop this type of harassment?
