| VADM CENTRE FOR ETHNIC MINORITY MENTAL HEALTH
Part 1: (Please answer ALL questions) |
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To be entered in to the prize draw, please enter you email address:
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| 1. Your Age at last birthday: |
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| 2. Your Gender: |
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| 3. Your Marital status: |
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| 4. How would you define yourself, ethnically? |
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| Any other ethnic background:
please specify? |
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| 5. What is the highest level of academic qualification you have attained? |
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| 6. What is your accessible annual income? |
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| 7. Below is a copy of the ‘von Luschan Skin Tone Chart’. This series does not represent all possible skin tones. Can you please indicate which skin tone most represents your own on an unexposed part of your body?
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| NEXT
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| Part 2:
Instructions: Each of the items below describes new situations that people encounter. Some people are concerned about these new situations and others are not. Please imagine yourself in each situation and indicate the number that best indicates how you would feel.
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1.
Imagine that you are in class one day, and the professor asks a particularly difficult question. A few people, including yourself, raise their hands to answer the question.
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a) How concerned/anxious would you be that the professor might not choose you because of your race/ethnicity?
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| very unconcerned very concerned
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| b) I would expect that the professor might not choose me because of my race/ethnicity.
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| Very unlikely
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Very unlikely
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| 2. Imagine that you are in a pharmacy, trying to pick out a few items. While you’re looking at the different brands, you notice one of the store clerks glancing your way.
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| a) How concerned /anxious would you be that the clerk might be looking at you because of your race/ethnicity |
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b) I would expect that the clerk might continue to look at me because of my race/ethnicity. |
Very unconcerned |
Very concerned |
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| Very unlikely |
Very likely |
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3. Imagine you have just completed a job interview over the telephone. You are in good spirits because the interviewer seemed enthusiastic about your application. Several days later you complete a second interview in person. Your interviewer informs you that they will let you know about their decision soon. |
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| a) How concerned/anxious would you be that you might not be hired because of your race/ethnicity? |
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| Very unconcerned
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Very concerned
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| b) I would expect that I might not be hired because of my race/ethnicity |
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| Very unlikely |
Very likely |
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| 4. It’s late at night and you are driving down a country road you’re not familiar with. Luckily, there is a 24-hour 7-11 just ahead, so you stop there and head up to the counter to ask the young woman for directions. |
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| a) How concerned/anxious would you be that she might not help you because of your race/ethnicity? |
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| Very unconcerned
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Very concerned
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| b) I would expect that the woman might not help me because of my race/ethnicity. |
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| Very unlikely |
Very likely |
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| 5. Imagine that a new school counsellor is selecting students for a summer scholarship fund that you really want. The counsellor has only one scholarship left and you are one of several students that is eligible for this scholarship. |
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a) How concerned/anxious would you be that the counsellor might not choose you because of your race/ethnicity? |
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| Very unconcerned |
Very concerned |
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b) I would expect that he might not select me because of my race/ethnicity. |
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| Very unlikely |
Very likely |
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| 6. Imagine you have just finished shopping, and you are leaving the store carrying several bags. It’s closing time, and several people are filing out of the store at once. Suddenly, the alarm begins to sound, and a security guard comes over to investigate. |
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a) How concerned/anxious would you be that the guard might stop you because of your race/ethnicity? |
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| Very unconcerned
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Very concerned |
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b) I would expect that the guard might stop me because of my race/ethnicity. |
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| Very unlikely |
Very likely |
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| 7. Imagine you are riding the bus one day. The bus is full except for two seats, one of which is next to you. As the bus comes to the next stop, you notice a woman getting on the bus. |
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a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity? |
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| Very unconcerned |
Very concerned |
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b) I would expect that the guard might stop me because of my race/ethnicity. |
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| Very unconcerned |
Very concerned |
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| 8. Imagine that you are in a restaurant, trying to get the attention of your waitress. A lot of other people are trying to get her attention as well. |
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a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity? |
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| Very unconcerned |
Very concerned |
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b) I would expect that the guard might stop me because of my race/ethnicity. |
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| Very unlikely |
Very likely |
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| 9. Imagine you’re driving down the street, and there is a police barricade just ahead. The police officers are randomly pulling people over to check drivers’ licenses and registrations. |
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a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity? |
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| Very unconcerned |
Very concerned |
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b) I would expect that the guard might stop me because of my race/ethnicity. |
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RBRS9b
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| Very unlikely |
Very likely |
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| 10. Imagine that it’s the second day of your new class. The teacher assigned a writing sample yesterday and today the teacher announces that she has finished correcting the papers. You wait for your paper to be returned. |
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a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity? |
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| Very unconcerned |
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b) I would expect that the guard might stop me because of my race/ethnicity. |
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| Very unlikely |
Very likely |
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| 11. Imagine that you are standing in line for the ATM machine, and you notice the woman at the machine glances back while she’s getting her money. |
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a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity? |
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| Very unconcerned |
Very concerned |
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b) I would expect that the guard might stop me because of my race/ethnicity. |
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| Very unlikely |
Very likely |
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| 12. Imagine you’re at a pay phone on a street corner. You have to make a call, but you don’t have change. You decide to go into
a store and ask for change for your bill |
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a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity? |
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| Very unconcerned |
Very concerned |
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b) I would expect that the guard might stop me because of my race/ethnicity. |
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| Very unconcerned |
Very likely |
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NEXT
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| Part 3:
Instructions: This part of the questionnaire looks at how you represent relationships within your own mind. Please read each statement carefully, and highlight the answer that best describes your experience.
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| 1) When I close my eyes and think about my past experiences, most of the images that come to mind are of me with:
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| a) ) People who make racist comments about other minoirty ethnic people, but it’s not serious, and it doesn’t involve me.
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| b) People who make insulting remarks about other minoirty ethnic people, but they always make a point of excluding me:
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| c) People who never mention the colour of my skin, my hair texture, or the thickness of my lips, but I know they have a significant effect on how they respond to me:
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| d) People like to socialise with me, but they wouldn’t want other people like me to have a personal relationship with any member of their families:
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| 2) When I close my eyes and think about my past experiences, most of the images that come to mind of me with:
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| a) People who make racist remarks about some aspect of my physical body.
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| b) People who tell me how much they don't like the darkness of my skin colour, my lips or texture of texture:
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| c) People who make racist jokes, and usually direct them at me.
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| d) People who say insulting things about my skin colour, shape of my nose, or the thickness of my lips, and don’t seem to care if it makes me feel unwanted and unhappy.
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| 3) When I close my eyes and think about my past experiences, most of the images that come to mind show me with:
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| a) People who rarely, if ever, socialise with anyone who is not from the same ethnic/racial background.
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| b) People who often make more positive remarks about the colour of my skin, the shape of my nose, texture of my hair, or thickness of my lips, than they do people from other racial backgrounds
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| c) People who made me feel valued as minoirty ethnic person, more so than they do about people from other racial backgrounds
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| d) People who prefer to be with other people from the same ethnic/racial background; to the exclusion of people from other racial backgrounds.
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| 4) When I close my eyes and think about my past experiences, most of the images that come to mind show me with:
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| a) People who value their own individual ethnic/racial identity, as much as they do, others.
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