Screening Questions for Bullying

Pediatrics
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Screening Questions for Bullying (I’d like to hear about how school is going...)

How many good friends do you have in school? [text]
Do you ever feel afraid to go to school? Why?
[textarea]


[select name="Q1" value="Never|Sometimes|Always"] <-- Do other kids ever bully you at school, in your neighborhood, or online? [conditional field="Q1" condition="(Q1).isNot('Never')"]
Who bullies you?
[textarea]
When and where does it happen?
[textarea]
What do they say or do?
[textarea][/conditional]


What do you do if you see other kids being bullied?
[textarea]
Who can you go to for help if you or someone you know is being bullied?
[textarea]
[html]<hr>[/html][checkbox memo="display/hide footnotes" name="footnotes" value=""][conditional field="footnotes" condition="(footnotes).is('')"][html]
footnotes: <a href="https://www.stopbullying.gov/resources-files/roles-for-pediatricians-tipsheet.pdf" target="_blank">www.stopbullying.gov</a>[/html][/conditional]
Screening Questions for Bullying (I’d like to hear about how school is going...)

How many good friends do you have in school?
Do you ever feel afraid to go to school? Why?



<-- Do other kids ever bully you at school, in your neighborhood, or online?


What do you do if you see other kids being bullied?

Who can you go to for help if you or someone you know is being bullied?


display/hide footnotes
Result - Copy and paste this output:

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