Harassment and Discrimination Survey

Note: The more information you are willing to share, the more helpful your survey will be to us.  However, if you do not feel comfortable with a question, feel free to skip it.  Also, while we will be accepting anonymous surveys, we would much prefer it if you would give us your name (in whole or in part).  School administrators often claim that bullying and discrimination don’t exist at their school, so the more we can put a “face” on the problem, the more persuasive your story will be.  If you have any questions, email them to changemyschool@gmail.com.

Thank you.


1. Personal Information (optional but preferred)

 
a. First name   b. Last name
     
 
c. email address   d. Telephone number
     

* We will not use the personal information you fill out above without your permission. (Please see the last question of survey for permission request.)


2. School Information

 
a. School   b. District
     
 
No
c. Years attended   d. Are you still enrolled? e. If yes, what grade will you be in for the 2007-2008 school year?
     


3. Student Safety Questions

a. Have you ever skipped classes because you felt uncomfortable or unsafe?
No
b. Have you ever skipped school entirely because you felt uncomfortable or unsafe either at school or on your way to or from school?
No
c. Have you ever felt unsafe at school because of (select all that apply):
your sexual orientation (either your “actual” sexual orientation, meaning how you self-identify, or your “perceived” sexual orientation, meaning how others might identify you)
how you express or identify your gender (for example, acting too “feminine” for a boy or too “masculine” for a girl or identifying as transgender)
d. On account of the reason(s) you selected above, have you ever…
… been verbally harassed at school? 
… been physically harassed (shoved, pushed, etc) at school? 
… been physically assaulted (punched, kicked, injured with a weapon) at school? 
… been sexually harassed (verbally or physically) at school? 
… had your property stolen or damaged (ex: car, clothing, books, etc.)? 
… had mean rumors or lies spread about you by students at school? 
… felt that you were treated unfairly by teachers or administrators? 
   
e. If you were harassed in the presence of a teacher or other school official, how often did that person stop the harassment?
Always
Most of the time
Some of the time
Never
   
f. If you were harassed, did you ever report it to a school official? 
No
g. Did the school official(s) help? 
No
h. If so, please briefly describe what they did:  
 
i. If you are no longer enrolled in school, did you graduate? 
No
j. If not, did you stop attending because of harassment or bullying on account of your sexual orientation or gender? 
No
k. If your school enacted a policy that specifically banned sexual orientation and gender identity discrimination, would you feel safer at school? 
No
l. Would you like it if your school enacted such a policy? 
No
m. Why or why not?  
n. Please list any specific experiences where you have faced harassment or discrimination from teachers, students, or administration on account of your actual or perceived sexual orientation, gender identity, expression, or appearance.  Include as many details as possible.

 

4. Request for Permission

Would you be willing to share your story publicly? 
No

(If yes, please make sure you have completely filled out the personal information section.)
 
 
 
   

 

Thank you for helping to change your school!

MNPS: Support Student Safety is not affiliated with the Metro Nashville Public School district.