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* 1. What is the name of your school or in what town is it located?

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* 2. What are the first 3 letters of your last name?  For example, if your last name is Smith, your initials would be SMI

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* 3. What is your birthdate? (mm/dd/yyyy) For example, 12/12/2010

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* 4. How old are you?

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* 5. What grade are you in?

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* 6. Are you a member of a tribe?

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* 7. If yes, how often do you feel like you are a part of, or belong to your tribe?

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* 8. Please check the answer that  most represents you.

  Strongly agree Agree Undecided Disagree Strongly disagree
On the whole, I am satisfied with myself
At times, I think I am no good at all
I feel that I have a number of good qualities
I am able to do things as well as most other people
I feel I don't have much to be proud of
I certainly feel useless at times
I feel that I am a person of worth, at least on an equal plane with others
I wish I could have more respect for myself
All in all, I am inclined to feel that I am a failure
I take a positive attitude toward myself
If you are in grades 3 - 8, you are finished!  Thank you for completing this survey!

If you are in high school, there is one more set of questions for you to answer so please continue.

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* 9. If you are in the 9th - 12th grades, please check the answer that most represents how you think or behave.

  Almost always Quite often Sometimes Not very often Never
I have strong convictions about things
When I believe in something, I work to promote it
I listen to both sides of the issue before I make up my mind
I have self-confidence
I am able to say my opinions in public
I usually am satisfied with the decisions I make
When I am criticized for some action I have taken, I can usually go about my work
I like to be in charge of events
I am able to see what supplies I need to complete a project
I am able to see the sequence of steps needed to complete a project
When I am convinced of something, I have courage to act for it
I often lead in projects
When I see somebody who is a leader, I think that I could do as well as that person
I can speak to persons in authority
I have energy to complete projects that I am interested in completing
I can understand the viewpoints of others
I am willing to change my mind if new facts suggest I should
I get anxious and excited and am able to use this energy to complete a task
I am able to work with many types of persons and personalities
I usually understand the plot of a story or play, or the main point in a conversation
I am willing to try new experiences when these seem wise
I know when to lead, when to follow, and when to get out of the way
I admire people who have achieved great things
I dream of the day and time when I am able to lead myself or others to great accomplishments
I feel at ease asking people for help or information
I can be a 'peacemaker' if I want to be
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