Interviews

Analysis of State Bullying Laws and Policies

APPENDIX S District and School Personnel Survey Forms

Interviews

OMB: 1875-0261

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District Bullying Survey—

Version for Use with District Representative

Form Approved

OMB No. Pending

Exp. Date: _________


Paperwork Reduction Act of 1995 Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20202-4536 or email ICDocketMgr@ed.gov and reference the OMB Control Number XXXX-XXXX.


This brief set of survey items is designed to capture information about your role addressing issues of school bullying and the nature and prevalence of bullying within your district’s schools. Please take a few minutes to answer the following questions.


  1. What is your position within the district? _________________________________________

  1. How long have you worked for the district in this position?

  • Less than one year

  • 5 to 9 years

  • 1 to 2 years

  • 10 years or more

  • 3 to 4 years


  1. What percentage of your time do you spend on bullying issues?

  • Less than 5%

  • 31 to 50%

  • 5 to 10%

  • 51 to 75%

  • 11 to 30%

  • More than 75%

  1. Thinking about the bullying behavior that occurs among students in your school district,
    to what extent does each of the following types of bullying create a disruption to the school environment within your district’s schools?


No
Disruption

Minor
Disruption

Some
Disruption

Substantial
Disruption

  1. Direct forms of aggression, such as physical or verbal acts

  1. Indirect forms of aggression to damage social relationship or status

  1. Cyberbullying or bullying using electronic communications

  1. How common is it for students to be bullied based on each of the following characteristics?


Not at all Common

Not Very Common

Somewhat Common

Very Common

Extremely Common

  1. Academic status

  1. Culture or cultural practices

  1. Dating or sexual history

  1. Gender

  1. Gender identity or expression

  1. Income/Socio-economic status

  1. Legal status (i.e., immigration)

  1. Physical appearance (i.e., weight, height, style of dress, perceived attractiveness)

  1. Physical, emotional, or developmental disability

  1. Race or ethnicity

  1. Religion or religious practices

  1. Sexual orientation

  1. No clear motivation based on characteristics

  1. Other, please specify: _______________________________________________________________________________



School Bullying Survey—

Version for Use with School Administrators, Teachers, Physical Education Teachers, Special Education Teachers, School Counselor/Psychologist, School Resource Officer

Form Approved

OMB No. Pending

Exp. Date: _________


Paperwork Reduction Act of 1995 Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20202-4536 or email ICDocketMgr@ed.gov and reference the OMB Control Number XXXX-XXXX.


This brief set of survey items is designed to capture information about the nature and prevalence of bullying within your school. Please take a few minutes to answer the following questions


  1. How frequently do you respond to bullying-related problems on your school campus? Specifically:


Everyday

Three or Four Times a Week

Once or Twice a Week

Once or Twice a Month

Once or Twice a Year

Never

  1. How often do you respond to problems related to direct and indirect acts of bullying (excluding cyberbullying)?

  1. How often do you respond to problems related to cyberbullying?

  1. Thinking about the bullying behavior that occurs among students in your school,
    to what extent does each of the following types of bullying create a disruption to the school environment?


No
Disruption

Minor
Disruption

Some
Disruption

Substantial
Disruption

  1. Direct forms of aggression, such as physical or verbal acts

  1. Indirect forms of aggression to damage social relationship or status

  1. Cyberbullying or bullying using electronic communications

  1. How common is it for students to be bullied based on each of the following characteristics?


Not at all Common

Not Very Common

Somewhat Common

Very Common

Extremely Common

  1. Academic status

  1. Culture or cultural practices

  1. Dating or sexual history

  1. Gender

  1. Gender identity or expression

  1. Income/Socio-economic status

  1. Legal status (i.e., immigration)

  1. Physical appearance (i.e., weight, height, style of dress, perceived attractiveness)

  1. Physical, emotional, or developmental disability

  1. Race or ethnicity

  1. Religion or religious practices

  1. Sexual orientation

  1. No clear motivation based on characteristics

  1. Other, please specify: _______________________________________________________________________________


School Bullying Survey—

Version for Use with Yard Supervisors and Transportation Personnel

Form Approved

OMB No. Pending

Exp. Date: _________


Paperwork Reduction Act of 1995 Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20202-4536 or email ICDocketMgr@ed.gov and reference the OMB Control Number XXXX-XXXX.


This brief set of survey items is designed to capture information about the nature and prevalence of bullying within your school. Please take a few minutes to answer the following questions


  1. How frequently do you respond to bullying-related problems on your school campus? Specifically:


Everyday

Three or Four Times a Week

Once or Twice a Week

Once or Twice a Month

Once or Twice a Year

Never

  1. How often do you respond to problems related to direct and indirect acts of bullying (excluding cyberbullying)?

  1. How often do you respond to problems related to cyberbullying?

  1. How common is it for students to be bullied based on each of the following characteristics?


Not at all Common

Not Very Common

Somewhat Common

Very Common

Extremely Common

  1. Academic status

  1. Culture or cultural practices

  1. Dating or sexual history

  1. Gender

  1. Gender identity or expression

  1. Income/Socio-economic status

  1. Legal status (i.e., immigration)

  1. Physical appearance (i.e., weight, height, style of dress, perceived attractiveness)

  1. Physical, emotional, or developmental disability

  1. Race or ethnicity

  1. Religion or religious practices

  1. Sexual orientation

  1. No clear motivation based on characteristics

  1. Other, please specify: _______________________________________________________________________________


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