Just for Educators

Student Assessment Form

1) What school do you attend? ____________________________________________________
2) What grade are you in? _______________________________________________________
3) What is your gender?_________________________________________________________

Circle the correct answer:
4) Do you feel like you should be a positive example for your peers?
Always | More Often | Sometimes | Less Often | Never

5) Do you feel like a leader in your family?
Always | More Often | Sometimes | Less Often | Never

6) Do you sacrifice for your family?
Always | More Often | Sometimes | Less Often | Never

7) Do you display frustration when something is not going your way?
Always | More Often | Sometimes | Less Often | Never

8) Do you influence others to do the right thing?
Always | More Often | Sometimes | Less Often | Never

9) Do you help others deal with failure?
Always | More Often | Sometimes | Less Often | Never

10) Do you think you are a motivated person?
Always | More Often | Sometimes | Less Often | Never

11) Do you believe you can reach your goals?
Always | More Often | Sometimes | Less Often | Never

12) Are you committed to working hard?
Always | More Often | Sometimes | Less Often | Never

13) Do you understand that there are consequences to actions?
Always | More Often | Sometimes | Less Often | Never

14) Are you trusting of others?
Always | More Often | Sometimes | Less Often | Never

15) Do you have faith in yourself?
Always | More Often | Sometimes | Less Often | Never

16) Do you accept new challenges?
Always | More Often | Sometimes | Less Often | Never

17) Do you learn from your failures?
Always | More Often | Sometimes | Less Often | Never

18) Do you appreciate it if someone helped you achieve success?
Always | More Often | Sometimes | Less Often | Never

19) Do you sacrifice time for others?
Always | More Often | Sometimes | Less Often | Never

20) Do you think you are trustworthy?
Always | More Often | Sometimes | Less Often | Never

21) Do you follow through with commitments?
Always | More Often | Sometimes | Less Often | Never


22) Do you believe in honesty in every situation?
Always | More Often | Sometimes | Less Often | Never

23) Do you think that you are a good example to others?
Always | More Often | Sometimes | Less Often | Never

24) Do you value the opinions of others?
Always | More Often | Sometimes | Less Often | Never

25) Do you accept and appreciate your competitors?
Always | More Often | Sometimes | Less Often | Never

26) Do you believe your peers behave from a good set of values?
Always | More Often | Sometimes | Less Often | Never

27) Do you appreciate authority figures?
Always | More Often | Sometimes | Less Often | Never

28) Do you know your boundaries when working with an authority figure?
Always | More Often | Sometimes | Less Often | Never

29) Do you feel supported by your family?
Always | More Often | Sometimes | Less Often | Never

30) Do you respect and care for your family?
Always | More Often | Sometimes | Less Often | Never

31) Are you selfish with things you have?
Always | More Often | Sometimes | Less Often | Never

32) Do you have to be told to do something before taking action?
Always | More Often | Sometimes | Less Often | Never

33) Do you like the feeling of helping your family?
Always | More Often | Sometimes | Less Often | Never

34) Do you take it upon yourself to show others how to reach their goals?
Always | More Often | Sometimes | Less Often | Never

35) Do you realize that your actions influence those around you?
Always | More Often | Sometimes | Less Often | Never

36) Do you set goals for yourself?
Always | More Often | Sometimes | Less Often | Never

37) Do you see drug use among your peers?
Always | More Often | Sometimes | Less Often | Never

38) Do you sense things aren’t well at home with your peers?
Always | More Often | Sometimes | Less Often | Never

39) Do your peers talk to you about any abuse they may be suffering?
Always | More Often | Sometimes | Less Often | Never

40) Do you support and care for your peers?
Always | More Often | Sometimes | Less Often | Never

41) Are you willing to take action when someone needs your help?
Always | More Often | Sometimes | Less Often | Never

42) Do you feel your peers are honest?
Always | More Often | Sometimes | Less Often | Never