Item No.

Always Sometimes Never

1. I experienced
teasing or
name- calling
at school
2. My friends
have negative
rumors, gossip
and secrets
been told
about me at
school.
3. I feel
uncomfortable
when someone
said something
cruel toward
me.
4. I found teasing
and name -
calling fun.
5. I think bullying
helps people
by making
them tougher
Name of Student: ___________________ Date:______________

Grade Level and Section: _______________

A. Verbal Bullying

B. TARDINESS

Item Number Always Sometimes Never

1. I make sure
that I come to
school on time.
2. I believe in the
value of
punctuality.
3. I participate in
classroom
discussion
regularly.
4. I make sure
that I submit
my activities
and projects
on time.
5. I work hard to
impress my
teachers on my
classroom
performance.

C. ABSENTEEISM

Item Number Always Sometimes Never

1. I am happy
with my
school.
2. I believe that
our school has
safe
environment
and conducive
to learn
3. I am bit upset
when I was
absent from
school.
4. I believe that
school is the
best place to
start my
dreams in life.
5. My teacher
seems
dedicated and
approachable.

D. SOCIAL MEDIA

Item Number Always Sometimes Never

1. I spend my
time playing
online games.
2. I am happy use
social
 networking
site like
facebook,
twitter,
youtube etc..
3. I learn to
manage my
time in
browsing in
the internet
4. I enjoy playing
online games
such as ML,
Clash of Clans,
Call of Duty
etc..
5. I can express
my feelings
and insights
through social
media

E. LIVING CONDITION

Item Number Always Sometimes Never

1. Our house is
comfortable to
live in
2. I can rest
comfortably at
home.
3. I can have my
meal regularly
at home.
4. I have my
allowance for
my school
needs.
5. I am happy of
what food we
shared in the
table at home.