A Guided Questionnaire Checklist on Students Behavior Who Experienced

Bullying

Dear students,

Please answer the items in the survey honestly. Your name and answers will be kept confidential.

Part I. Request you to fill relevant information about yourself.

Name (Optional)

Grade Level

Date

Mark check (√ ) on the box which corresponds to your answer.

Age Gender

12-13 Male

14-15 Female

16-17 Lesbian

18-19 Gay
Part II. Please write checkmark () to your corresponding answers regarding your behavior towards Bullying: (5)
means always, (4) means most of the time, (3) means sometimes, (2) means rarely and (1) means not at all. Please
answer honestly.

Questions: Always Most of Sometimes Rarely Not at all

(5) the time (3) (2) (1)
(4)
1) Did you ever bully someone?
2) Did you experience being
bullied?
(Please indicate the type)
a) Verbal Bullying
b) Cyber Bullying
c) Physical Bullying
d) Emotional Bullying
3) Does bullying affect your
attendance in school?
4) Does an increase on the
irregularity of attendance is the
cause of bullying?
5) How about your performances?
Did you perform well?
6) Did you encounter some
changes in your behavior?
a) Like isolating
yourself from
others.
b) Being shy
c) Being weird
d) Being alone
e) Having low self-
esteem
f) Appetite to eat
7) Do you fear your peers?
8) Do you fear your classmates?
9) Do you experience low self-
esteem?
10) If you were being bullied do you
fight back?
11)Does bullying lower your self-
esteem?
12) Do you ever think to end your
life? If someone bullies you?
 How can you prevent from being bullied?