Age:_____________ Grade:___________ Hometown:__________ Race:______________ Male or Female:____________ Does your school require you to complete a minimum of community service hours? If yes, how many? ____________________________________________________________ ____________ Do you participate in volunteering or community service outside of school requirements? If yes, how many hours per week? ____________________________________________________________ _________ Instructions. This is a questionnaire about young people’s behavior, thoughts, and feelings in groups.

Try to imagine yourself in the given situations. Check the response that best describes how you would honestly react. Don’t spend too long on any one question; there is no right or wrong answer. 1. If you see two people talking and casually glancing your way, do you: ____ Feel sure they’re talking about you? ____ Think that it’s probably coincidence? ____ Check to see that you don’t look odd in any way? 2. Imagine that you and your friends are trying out a new dance at a party. It is turned into a competition and you reach the finals. Do you: ____ Feel silly because you don’t think you’re very good? ___ Try to perfect all the steps? ____ Wonder what others think of your dancing? 3. If on arrival at a party, you found a grease patch on your jeans, would you: ____ Not worry? ____ Go home because you think that everyone would notice? ____ Go home because you don’t feel right when you’re dirty? 4. If you got “tipsy” at a party and ended up dancing on a table, in front of everyone, how would you feel the next day? ____ A little nervous because you’d think everyone would mention it? ____ Uncomfortable because you don’t like acting the fool? ____ No different, you’d forget it? 5.

If you were suddenly asked to present a paper to the class, would you: ____ Be uncomfortable because you thought others were evaluating you? ____ Feel bad because you couldn’t present your best work in the short time available? ____ Not worry too much about it? 6. If you arrive late for a meeting, do you: ____Try to come in the back way because you think that everyone’s eyes will be on you? ____ Come in as unobtrusively as possible? ____ Feel bad for interrupting the meeting? 7. You are against uranium mining and asked to lead a demonstration. Would you: ____ Decline because you’d feel shy being at the front? ___ Decline because you think your friends would call you a “radical”? ____ Accept without a moment’s thought? 8. While opening a meeting, you accidentally spill something on a guest speaker. Is your first reaction to: ____ Think how clumsy everyone will think you are? ____ Feel embarrassed about the mess you’ve made? ____ Hope that it won’t leave a stain? 9. When you’re at a party and talking to someone of the opposite sex, do you: ____ Not act different than normal? ____ Usually feel shy and self-conscious? ____ Wonder what others are thinking about the two of you? 10.

It is the premiere of a film made by your school in which you played the lead role. What is your main concern: ____ That you don’t come across as well on film as on stage? ____ That everyone will think that you were not really suited to the part? ____ That the film goes well and will be a credit to your school? 11. If you and a group of friends arranged to meet at a coffee shop and you arrived first, you would: ____ Think that everyone was looking at you and wondering why you were there? ____ Order a coffee while you were waiting? ____ Feel uncomfortable because you were alone? 12.

You drop your knife with a loud clatter in a restaurant. Do you: ____ Imagine that everyone turned to see who made the noise? ____ Feel a fool for being so clumsy? ____ Pick it up and not worry about the noise? 13. If you go to a party where you hardly know anyone, do you: ____ Think that everyone will notice you’re a stranger? ____ Make the first move and introduce yourself to some people? ____ Feel awkward and stay in the background? 14. You have braces just put on your teeth, and are then asked to speak at a school conference. How do you feel: ____ Pleased that you have been asked? ___ Sure that everyone will notice how ugly you look? ____ Embarrassed because they make your voice sound a little funny? 15. If you went out with a person of the opposite sex who was six inches taller (boys) or shorter (girls) than you, would you: ____ Not feel right because you feel it should be the other way around? ____ Not worry about it and enjoy yourself? ____ Think that people would notice and consider it “odd”? 16. You can sing reasonably well and are asked to sing at a party. Do you: ____ Feel shy because your voice isn’t all that good? ___ Start singing and try to get others to join in? ____ Try to get out of it because you think that others will call you a show-off if you do? 17. You go to help someone who has fallen in a crowded street. As a small circle gathers round, do you: ____ Imagine that everyone thinks you’re a “busy-body”? ____ Feel ill at ease because you don’t have a knowledge of first aid? ____ Ask for assistance? 18. Imagine that you have moved to a new neighborhood. Would you: ____ Feel conspicuous because you think everyone watches “new” people? ____ Feel shy about making new friends? ___ Try to settle as quickly as possible? 19. It is your first day back at school after a long holiday overseas. Your friends have arranged a welcome home party for you. Do you: ____ Feel a bit nervous because you’re not sure how everyone will greet you? ____ Look forward to telling everyone about your experiences? ____ Think that everyone will notice you’ve put on some weight? 20. You can’t avoid walking through a group of people standing chatting together. As you pass through do you: ____ Not think twice about it? ____ Imagine that they are looking at you? ___Feel bad because you interrupted their conversation? 21. For the first time you are in the finals of an important swimming race. Do you: ____ Feel thrilled that you’ve reached the finals? ____ Worry that you’re not good enough? ____ Think that others are watching you loosely, and feel extra nervous? 22. At a party, your friends offer you a cigarette. You accept although you haven’t smoked before. Do you then: ____ Feel silly because you don’t know how to smoke? ____ Watch your friends and follow their example? ____ Think they’re looking at you and therefore try to do the drawback? Sur