1 – Not at all
2 – Once
3 – More than once
¹
1
2
3
1
Called me names.
2
Tried to get me into trouble with my friends.
3
Took something of mine without permission.
4
Made fun of me because of my appearance.
5
Made fun of me for some reason.
6
Punched me.
7
Kicked me.
8
Hurt me physically in some way.
9
Beat me up.
10
Tried to break something of mine.
11
Tried to make my friends turn against me.
12
Stole something from me.
13
Refused to talk to me.
14
Made other people not talk to me.
15
Deliberately damaged some property of mine.
16
Swore at me.
The presented answer sheet is not an original form and is not intended for printing or use as a handout.
The answer numbers are used only to label response columns. They are NOT scores and should not be used for calculating results.