SURVEY QUESTIONNAIRE

Research Title: “ASSESSMENT OF BULLYING INCIDENCE AMONG GRADE IX

STUDENTS OF POLONULING NATIONAL HIGH SCHOOL:
BASIS FOR THE DEVELOPMENT OF ANTI-BULLYING
PROGRAM”

Dear Respondents:
Please read the following statements carefully before answering and do not leave any
unanswered statement. Rest assured that all information and answers obtained from
the conduct of this study shall be treated with utmost confidentiality and will be used
solely for the purpose of this research.

Part 1. Demographic Profile of the Respondents

Instruction: Please indicate what is being asked and check the box that corresponds
to your answer.

Age: ____________

Parent’s Occupational Status: [] both parents are working

[] parents working abroad

[] parents staying at home

Sex: [ ] Male [ ] Female

Part II. Bullying Profile

Instruction: Please check the box that corresponds to your answer.

Have you experienced being bullied in school? [ ] Yes [ ] No

How often are you bullied in school?

[] once or twice [] frequent

Who bullied you in school?

[] friends [] classmates [] schoolmates

Where bullying is commonly experienced?

[] playground [] gym [] classroom
[] hallways [] canteen
What form/ in what way have you been bullied?
[] physically [] verbally

Part III. Common Effects of Bullying

Instruction: Please indicate what is being asked and check the box that
corresponds to your answer.

1. What is the effect of bullying to you?

[] gets angry
[] defends myself
[] losses confidence
[] chooses friends carefully
[] gets afraid in going to school
[] gets afraid of joining other activities
[] affects my ability to make friends
[] gets anxious/ depressed/ low self-esteemed
[] lacks interest in personal appearance
[] affects my physical/ emotional/ mental health
[] makes me distrustful of people/ adults in authority
[] lacks interest in school work and extra-curricular activities

Part IV. Coping Mechanism

[] I fought back
[] I tried to ignore it
[] I tried to make fun of it
[] I got help from my friends
[] I got help from my teacher
[] I tried to avoid the situation
[] I tried to handle it by myself
[] I got help from my parents
[] I tried to move on and forget about it
[] I pray