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| *Do you have access to the Internet at: (select all that apply) | Hold CTRL key while clicking to select more than one |
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| *Which of the following do you spend the greatest amount of time on? | |
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| *Which of the following do you spend the 2nd most amount of time on? | |
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| *Which of the following do you spend the 3rd most amount of time on? | |
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| *Which of the following do you spend the 4th most amount of time on? | |
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| *Which of the following do you spend the 5th most amount of time on? | |
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| *Which of the following do you spend the 6th most amount of time on? | |
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| *Which of the following do you spend the 7th most amount of time on? | |
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| *Which of the following do you spend the 8th most amount of time on? | |
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| *Which of the following do you spend the 9th most amount of time on? | |
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| *Which of the following do you spend the 10th most amount of time on? | |
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| If you answered yes to the above question, does it have: | Hold CTRL key while clicking to select more than one |
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| Have you ever received an intentionally hurtful or harassing comment through an electronic communication medium (Internet, or cell phone) at least once? | Hold CTRL key while clicking to select more than one |
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| If you have received, or been the target of any form of intentionally hurtful comments posted, or sent through an electronic communication medium, did the nature of the offensive comments about you fall into any of the following categories: | Hold CTRL key while clicking to select more than one |
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| Please provide an explanation for your answer above | |
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| Have you ever been lied to about someone's identity pertaining to any of the following? | Hold CTRL key while clicking to select more than one |
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| If you answered yes to question 32, were you accompanied by | Hold CTRL key while clicking to select more than one |
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| If you answered yes to question 35, who did you tell about the situation (select all that apply) | Hold CTRL key while clicking to select more than one |
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| If you answered yes to question 38, which of the following did you tell about the situation | Hold CTRL key while clicking to select more than one |
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| Do you know of any websites, chat rooms, message boards, or other sites where you have seen or know, that online harassment of young people in Brandon occurs? Please list. | |
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| If you would like to anonymously submit a description of your cyberbullying experience to us, please do so in the space provided below. Please provide as many details as you feel comfortable. | |
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