QUESTIONNAIRE

Name: (Optional)
School:

Directions: Please answer the questions based on your opinion following the
below rating scale.

Scale Value Range Verbal Interpretation

5 4.50 5.00 Always (A)
4 3.50 4.49 Often (O)
3 2.50 3.49 Sometimes (SM)
2 1.50 2.49 Seldom (SE)
1 1.00 1.49 Never (N)

Part I. Status of the Child Protection Policy Implementation in the school

A.Composition
Composition 5 4 3 2 1
The policy has Clear procedures and strategies for
Reporting acts of bullying or retaliation
Contains education of students on the dynamics of
bullying
The policy has well-organized team/committee to
manage bullying cases.
The policies are included in the handbook and
shall be conspicuously posted on the walls
The policy has a wide range of disciplinary
administrative actions
that may be taken against a perpetrator for
bullying or retaliation which shall be
commensurate with the nature and gravity of
the offense and a rehabilitation program
which shall be administered by the institution
concerned

B.Strategy
5 4 3 2 1
Restores a sense of safety for a victim and assessing
the students need for protection
Protecting from bullying or retaliation a person who
reports acts of bullying
Providing counseling or referral to appropriate
services for perpetrators, victims and appropriate
family members of said students
Follows mechanisms of such school for the
anonymous reporting of acts of bullying or retaliation
Teachers and other employees regularly attends
relevant trainings to develop their knowledge and
skills in preventing or responding to any bullying act

C.Reporting and Monitoring

5 4 3 2 1
The school has a complete and updated records of
reports on bullying.
The school principal or the designated officer or
person shall promptly investigate
Takes appropriate disciplinary administrative action.
Notifies the parents or guardians of the victim
regarding the
action taken to prevent any further acts of bullying or
retaliation
If an incident of bullying or retaliation involves
students from more than one school, the school first
informed of the bullying or retaliation shall promptly
notify the appropriate administrator of the other
school so that both may take appropriate action.
Source: Towards A Child Friendly Education Environment, PWU-CWC- UNICEF for
Plan Philippines in 2009

Part 2. Level of Causes of Bullying

A.Direct
5 4 3 2 1
Hitting (Pananakit ng kaklase)
Pushing or Tripping (Pagtutulakan at Pagtalakid)
Slapping (Pananampal)
Spitting (Pandudura sa kaklase)
Stealing or destroying possessions, including books,
clothing, or lunch money (Pagsira o pagkuha ng
gamit na hindi iyo)

B.Indirect
5 4 3 2 1
Excluding a particular classmate from an activity,
conversation or other group setting
Mocking someone for something about their
appearance or personality
Gossiping about another classmate which is not true.
Tells lies to protect him/her against other classmates.
Saying hurtful words and nicknames to classmates.

Part 3. Extent of Effects of Bullying to Pupils

A.Physical
Physical 5 4 3 2 1
1. Coming home from school with bruises, cuts,
or other unexplained injuries
2. Having damaged clothing, books, or
possessions
3. Trying to take a weapon to school.
4. Inflicting harm to self or other classmates.
5. Complaining of frequently not feeling well
before school or school activities

B.Academic Performance
5 4 3 2 1
1. Does not want to go to school
2. Rarely participates in school activities
3. Skipping classes
4. Dropping out of school
5. Low grades in tests and other quizzes

C.Emotional
5 4 3 2 1
1. Acting sad or depressed while in school and
home
2. Wants to be alone and not join other
classmates
3. Persistent mood swings, including anger or
sadness
4. Wanting to run away from school
5. Thinks of dropping out of school