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* 1. Please select your child's school:

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* 2. Please select your child's grade level:

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* 3. Please give the current city or town you live in:

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* 4. Please select your appropriate ethnicity:

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* 5. My child's identified gender is:

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* 6. My child likes to come to school each day:

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* 7. I feel the students in this school are kind:

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* 8. I feel that this school is physically safe:

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* 9. I feel comfortable sharing my thoughts and ideas at this school:

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* 10. I feel my child's peers treat him/her fairly:

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* 11. I feel the adults in my child's school treat me fairly:

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* 12. I feel there are trusted adults in the school who my child can go to/talk to for help:

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* 13. When my child rides the bus, the trip to and from school is a positive/safe experience:

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* 14. My child is involved in extra-curricular activities such as athletics, clubs, activities, school committees,  musical/play, volunteering, employment etc.:

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* 15. My child has been the target of hurtful communications through technology (i.e. social media, online posts, texting etc.):

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* 16. My child has participated in hurtful communications through technology (i.e. social media, online posts, texting etc.):

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* 17. Do you feel that there is an area of the school that is not safe? If yes, where?

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* 18. How often do you communicate, other than reporting absences and dismissals, (in person, phone calls, emails, etc.) with your child's school during the year?

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* 19. In my child's school, there are clear rules against intentionally harming other people (for example, hitting, pushing, or tripping):

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* 20. I have seen students at my child's school being physically hurt by other students more than once (for example, pushed, slapped, punched):

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* 21. There are students in the school who intentionally exclude others and make them feel bad for not being a part of the group:

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* 22. Students at my child's school will try to stop students from insulting or making fun of other students:

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* 23. Students in my child's school respect each other's differences (for example, gender, race, culture, disability, sexual orientation, learning differences, etc.):

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* 24. Families feel welcome at my child's school:

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* 25. One more thing I would like to say:

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