DAP-Sample-Survey-Page

DEVELOPMENTAL ASSETS PROFILE                                        (DAP) Sample Page
                                                         Self-Report for Ages 11-18
NAME / ID:                                                                    TODAY’S DATE:            Mo:             Day:            Yr:
SEX: † Male        † Female           AGE:               GRADE:               BIRTH DATE:              Mo:             Day:            Yr:
RACE/ETHNICITY (Check all that apply):                   † American Indian or Alaska Native                         † Asian
† Black or African American                † Hispanic or Latino/Latina                   † Native Hawaiian or Other Pacific Islander
† White                                    † Other (please specify):
INSTRUCTIONS: Below is a list of positive things that you might have in yourself, your family, friends, neighborhood,
school, and community. For each item that describes you now or within the past 3 months, check if the item is true:
          Not At All or Rarely           Somewhat or Sometimes                   Very or Often           Extremely or Almost Always
If you do not want to answer an item, leave it blank. But please try to answer all items as best you can.
 Not At All   Somewhat       Very      Extremely
    or           or           or          or
  Rarely      Sometimes      Often   Almost Always
                                                              I...
    †            †            †            †             1. Stand up for what I believe in.
    †            †            †            †             2. Feel in control of my life and future.
    †            †            †            †             3. Feel good about myself.
    †            †            †            †             4. Avoid things that are dangerous or unhealthy.
    †            †            †            †             5. Enjoy reading or being read to.
    †            †            †            †             6. Build friendships with other people.
    †            †            †            †             7. Care about school.
    †            †            †            †             8. Do my homework.
    †            †            †            †             9. Stay away from tobacco, alcohol, and other drugs.
    †            †            †            †             10. Enjoy learning.
    †            †            †            †             11. Express my feelings in proper ways.
    †            †            †            †             12. Feel good about my future.
    †            †            †            †             13. Seek advice from my parents.
    †            †            †            †             14. Deal with frustration in positive ways.
    †            †            †            †             15. Overcome challenges in positive ways.
    †            †            †            †             16. Think it is important to help other people.
    †            †            †            †             17. Feel safe and secure at home.
    †            †            †            †             18. Plan ahead and make good choices.
    †            †            †            †             19. Resist bad influences.
    †            †            †            †             20. Resolve conflicts without anyone getting hurt.
    †            †            †            †             21. Feel valued and appreciated by others.
    †            †            †            †             22. Take responsibility for what I do.
    †            †            †            †             23. Tell the truth even when it is not easy.
    †            †            †            †             24. Accept people who are different from me.
    †            †            †            †             25. Feel safe at school.

                                       PLEASE TURN OVER AND COMPLETE THE BACK.
        Copyright © 2004, Search Institute, Minneapolis, MN; 800-888-7828; www.search-institute.org. All rights reserved. Do not reproduce.