Please review the assent form (page 3 is for participants under age 18 years) before you begin

By completing the survey I confirm I have reviewed the consent and or assent for this study and have had the opportunity to print or download my own copy

Section 1

1. Sex

A. Female

B. Male

C. Other

2. Race

A. African American

B. Asian

C. Indian

D. White

E. Mixed Race

F. Prefer not to answer

3. Ethnicity

A. Hispanic

B. Not Hispanic

C. Prefer not to answer

4. Age range

A. 8-11

B. 12-14

C. 15-17

D. 18-21

E. 22 or older

5. Food allergy(s) mark all that apply

A. Peanut

B. Tree nuts

C. Milk

D. Egg

E. Fish

F. Shellfish

G. Wheat

H. Soy

Other

6. Have you ever used an epinephrine auto injector (for example Epipen, Auvi-Q or generic epinephrine device) for a food allergy reaction?

Yes No

Section 2

1. Have you ever been bullied, teased or harassed for any reason?

Yes No (if no, then please go to the end of the survey now and press submit as you are finished)

2. Have you ever been bullied, teased or harassed about your food allergies?

Yes No (if no, then please go to the end of the survey and press submit as you are finished)

If Yes, was it more than once?

Yes No (if no, then please go to the end of the survey and press submit as you are finished)

3. Who bullied, teased or harassed you about your food allergies (check all that apply)?

A. Classmate(s)

B. Friend(s)

C. Teacher(s)

D. Coworker(s)

E. Sibling(s)

F. Other family member

Other

4. Why do you think you were bullied, teased or harassed about your food allergies? Mark all that apply

A. Only because of the food allergy

B. Having to carry or wear an Epipen or Epinephrine injector (Auvi-Q, generic epinephrine injector, etc)

C. Having to eat in a special place away from others

D. Because of special treatment you received

Other

5. How were you bullied, teased or harassed regarding your food allergy?

A. With teasing or taunting words?

Yes No

B. With sarcastic remarks or criticism?

Yes No

C. Words used to threaten you with the food you are allergic to?

Yes No

D. Were you intentionally ignored or excluded because of your food allergy?

Yes No

E. Were rumors spread about you because of your food allergy?

Yes No

6. Did any of the above bullying, teasing or harassment take place using

A. A computer, tablet or phone with messaging or email?

Yes No

B. Social media

Yes No

If Yes which one? Mark all that apply

A. Facebook

B. Instagram

C. Snapchat

D. TikTok

Other

C. Online gaming?

Yes No

If Yes, which game?

D. Other online chat or instant messaging

Yes No

If Yes, which one?

E. YouTube

Yes No

F. Online documents or projects (Google Docs, Microsoft Teams etc)

Yes No

G. Other forms of electronic communication?

H. None of these

Yes No

7. Have you ever experienced someone pretending to be someone else online in order to obtain or post personal or false information about you due to your food allergies?

Yes No

8. Has anyone ever? Mark all that apply:

A. Waived a food that you are allergic to in front of your face or body?

B. Thrown a food that you are allergic to at you?

C. Touched you with a food you are allergic to?

D. Intentionally put a food you are allergic to in your food?

E. Pushed, tripped, hit or kicked you because of your allergy?

F. Any other form of hurting you in person because of your food allergy

G. None of the above

9. Have you ever been told of a bullying, teasing or harassment incident about your food allergies that you were not present for (for example behind your back) by a family member, peer, friend or co-worker?

Yes No

10. How has food allergy bullying, teasing or harassment affected you? Mark all that apply:

A. Made me feel sad or depressed

B. Made me feel embarrassed or humiliated

C. Made me feel nervous or anxious

D. Made me feel lonely or withdraw from social situations

E. Caused me to have low self-esteem

F. Made me lose sleep or feel tired

G. Caused me to have poor grades or work performance

Other

11. Have you ever reported in person bullying, teasing or harassment about your food allergies to anyone?

Yes No

If Yes, was it to a (check all that apply)

A. Parent

B. Parent

C. Friend

D. Co-worker

E. Supervisor

Other

12. Have you ever reported electronic or cyber bullying, teasing or harassment to anyone?

Yes No

If Yes, was it to a (mark all that apply)?

A. Parent

B. Teacher

C. Friend

D. Co-worker

E. Supervisor

Other

This is the end of the study questions. Please click submit below to complete the survey. Thank you!

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