Please read each and mark if this appears in your life. A big

YES means definitely, a little yes mean pretty much and big NO Never ever and a little no means just sometimes.

THIS IS ALL CONFIDENTIAL

First Name

Last Name

Support

1. Family Support- My family provides high levels of love and support.

YES

yes

no

NO

2. Positive Family Communication- My parent(s) and I communicate positively, and I am willing to seek advice and counsel from my parent(s).

YES

yes

no

NO

3. Other Adult Relationships- I receive support from three or more nonparent adults.

YES

yes

no

NO

4. Caring Neighborhood- I have caring neighbors.

YES

yes

no

NO

5. Caring School Climate- My school provides a caring, encouraging environment.

YES

yes

no

NO

6. Parent Involvement in Schooling- My parent(s) are actively involved in helping me succeed in school.

YES

yes

no

NO

Empowerment

7. Community Values Youth- I believe that adults in the community value youth.

YES

yes

no

NO

8. Youth as Resources- I believe young people are given useful roles in the community.

YES

yes

no

NO

9. Service to Others- I serve in the community one hour or more per week.

YES

yes

no

NO

10. Safety- I feel safe at home, school, and in the neighborhood.

YES

yes

no

NO

Boundaries & Expectations

11. Family Boundaries- My family has clear rules and consequences and monitors my whereabouts.

YES

yes

no

NO

12. School Boundaries- My school provides clear rules and consequences.

YES

yes

no

NO

13. Neighborhood Boundaries- My neighbors take responsibility for monitoring my behavior.

YES

yes

no

NO

14. Adult Role Models- My parent(s) and other adults model positive, responsible behavior.

YES

yes

no

NO

15. Positive Peer Influence- My best friends model responsible behavior.

YES

yes

no

NO

16. High Expectations- Both parent(s) and teachers encourage me to do well.

YES

yes

no

NO

Constructive Use of Time

17. Creative Activities- I spend three or more hours per week in lessons or practice in music, theater, or other arts.

YES

yes

no

NO

18. Youth Programs- I spend three or more hours per week in sports, clubs, or organizations at school and/or in the community.

YES

yes

no

NO

19. Religious Community- I spend one or more hours per week in activities in a religious institution.

YES

yes

no

NO

20. Time at Home- I am out with friends "with nothing special to do" two or fewer nights per week.

YES

yes

no

NO

Commitment to Learning

21. Achievement Motivation- I am motivated to do well in school.

YES

yes

no

NO

22. School Engagement- I am actively engaged in learning.

YES

yes

no

NO

23. Homework- I do at least one hour of homework every school day.

YES

yes

no

NO

24. Bonding to School- I care about my school.

YES

yes

no

NO

25. Reading for Pleasure- I read for pleasure three or more hours per week.

YES

yes

no

NO

Positive Values

26. Caring- I place high value on helping other people.

YES

yes

no

NO

27. Equality and Social Justice- I place high value on promoting equality and reducing hunger and poverty.

YES

yes

no

NO

28. Integrity- I act on convictions and stand up for my beliefs.

YES

yes

no

NO

29. Honesty- I "tell the truth even when it is not easy."

YES

yes

no

NO

30. Responsibility- I accept and take personal responsibility.

YES

yes

no

NO

31. Restraint- I believe it is important not to be sexually active or to use alcohol or other drugs.

YES

yes

no

NO

Social Competencies

32. Planning and Decision Making- I know how to plan ahead and make choices.

YES

yes

no

NO

33. Interpersonal Competence-I have empathy, sensitivity, and friendship skills.

YES

yes

no

NO

34. Cultural Competence- I have knowledge of and comfort with people of different cultural/racial/ethnic backgrounds.

YES

yes

no

NO

35. Resistance Skills- I can resist negative peer pressure and dangerous situations.

YES

yes

no

NO

36. Peaceful Conflict Resolution- I seek to resolve conflict nonviolently.

YES

yes

no

NO

Positive Identity

37. Personal Power- I feel I have control over "things that happen to me."

YES

yes

no

NO

38. Self-Esteem- I have a high self-esteem.

YES

yes

no

NO

39. Sense of Purpose- I would say “my life has purpose.”

YES

yes

no

NO

40. Positive view of personal future- I am optimistic about my personal future.

YES

yes

no

NO

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