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This survey will [PROBABLY] be taken on surveymonkey.com, but this is the hard copy, and the online survey preview is the URL link.
1. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
2. What is your gender?
Gender Queer/Gender Non-Conforming
3. What is your ethnicity? (Please select all that apply.)
American Indian or Alaskan Native
Asian or Pacific Islander
Black or African American
Hispanic or Latino
White / Caucasian
Prefer not to answer
Other (please specify)
4. On the whole, I am satisfied with myself.
5. At times, I think I am no good at all.
6. I feel that I have a number of good qualities.
7. I am able to do things as well as most other people.
8. I feel I do not have much to be proud of.
9. I certainly feel useless at times.
10. I feel that I’m a person of worth, at least on an equal plane with others.
11. I wish I could have more respect for myself.
12. All in all, I am inclined to feel that I am a failure.
13. I take a positive attitude toward myself.
14. For the next questions, answer them based off of the last four weeks.
OK, I shall do my best.
15. It has been easy to relate to others.
most of the time
about half of the time
not at all
16. I felt isolated from other people.
17. I had someone to share my feelings with.
18. I found it easy to get in touch with others when I needed to.
19. When with other people, I felt separate from them.
20. I felt alone and friendless.
not at all