BIZZNA TUTOR

Nicole Helms Survey and Informed consent

Nicole Helms

SURVEY ON BULLYING

I am: _____a teacher _____a student

Definition: Bullying is an unwanted, repetitive and perceived power imbalance. It can involve exclusion, threats, physical harm, mocking, theft, rumor spread, extortion, or use of unkind gestures.

Please circle your response to items 1-6

1. I have seen bullying at school within the past month.

Yes

No

2. If you reported bullying incidents at school, did you feel your concerns were taken seriously by the school administration?

Yes

No

3. Students enjoyed the read aloud book, Blubber, about students who bully, are bullied or witness bullying.

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

4. Students acquired important information from the discussion of the bullying book chaired by their teacher.

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

5. The lessons taught by the school counselor on bullying have been helpful.

Strongly agree

Agree

Neutral

Disagree

Strongly disagree

6. Please discuss what you think a student should do when he or she is bullied or witnesses another student being bullied. Use the back of this page for your response.

Thank you very much for participating in this survey project!

Informed consent

Bullying remains one of the biggest problems found in primary schools. We have all heard about bullying and its influence on students as a way of alleviating pain. The objective of this study will be to compare students’ and teachers’ views of selected aspects of bullying. Taking part in this survey will help us evaluate current practices and make schools safe places for our children.

Your name must not appear in the survey instrument for anonymity purpose. In addition, your responses will be treated confidentially. We value all information and encourage you to take your time to complete all the listed items. No one is forced to participate in the study. You are free to stop at any stage if you feel uncomfortable. This is a right and refusing to participate or withdrawing at any stage will not demoralize the researcher.

I have had a chance to ask questions about the research and all procedures and now grant my consent to participate.

___________________________ ________________

(Subject’s signature) (Date)

___________________________ ________________

(Witness’ signature) (Date)

___________________________ ________________

(Parent’s signature for minor) (Date)