Self Esteem Survey

First Name:

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* 1. First Name:

Last Name:

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* 2. Last Name:

I feel that I’m a person of worth, at least equal to others.

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* 5. I feel that I’m a person of worth, at least equal to others.

I feel that I have a number of good qualities.

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* 6. I feel that I have a number of good qualities.

All in all, I am inclined to feel that I’m a failure.

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* 7. All in all, I am inclined to feel that I’m a failure.

I am able to do things as well as most other people.

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* 8. I am able to do things as well as most other people.

I feel I do not have much to be proud of.

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* 9. I feel I do not have much to be proud of.

I take a positive attitude toward myself.

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* 10. I take a positive attitude toward myself.

On the whole, I am satisfied with myself

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* 11. On the whole, I am satisfied with myself

I wish I could have more respect for myself.

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* 12. I wish I could have more respect for myself.

I certainly feel useless at times.

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* 13. I certainly feel useless at times.

At times, I think that I am no good at all.

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* 14. At times, I think that I am no good at all.

Vaux A. Social support: theory, research, and intervention. New York, NY: Praeger, 1988.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. (2005). Violence-Related Attitudes, Behaviors, and Influences Among Youths: A
Compendium of Assessment Tools, 2nd ed. Atlanta, GA: Dahlberg LL, Toal SB, Swahn M, Behrens CB. Electronic version available: http://www.cdc.gov/ncipc/pub-res/measure.htm.

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