Part 1: (Please answer ALL questions)
To be entered in to the prize draw, please enter you email address:
1. Your Age at last birthday:
2. Your Gender:
3. Your Marital status:
4. How would you define yourself, ethnically?
	Any other ethnic background: please specify
5. What is the highest level of academic qualification you have attained?
6. What is your accessible annual income?
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? 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
NEXT

Part 2: Instructions: This questionnaire assesses concerns about physical appearance. Please read each question carefully and check the answer that best describes your experience. Also write in answers where indicated.
1. Do other people appear concerned about the appearance of some part of your body, which they consider especially unattractive??
2. What do think these concerns are? What specifically bothers them about the appearance of these body parts?
3. If, they are at least somewhat concerned, do these concerns preoccupy you? That is, you think about them a lot and they’re hard to stop thinking about? (Check the best answer )
4. What effect has their preoccupation with your physical appearance had on your life? Please describe):
5. Does their behaviour towards you often caused you a lot of distress, torment or pain? And if so how much? (Please check the best answer)
6. Has other people’s apparent concern with your physical appearance significantly interfered with your relationships at home, school, college, work, or your ability to function in your role or other important areas of your life? How much? (Please check the best answer)
7. Do you ever avoid things because of your physical “defect”? How often?? (Please check the best answer)
NEXT

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.
1) When I close my eyes and think about my past experiences, most of the images that come to mind are of me with:
a) ) People who make racist comments about other black people, but it’s not serious, and it doesn’t involve me.
b) People who make insulting remarks about other black people, but they always make a point of excluding me:
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:
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:
2) When I close my eyes and think about my past experiences, most of the images that come to mind of me with:
a) People who make racist remarks about some aspect of my black body.
b) People who tell me how much they don't like the darkness of my skin colour, my lips or texture of texture:
c) People who make racist jokes, and usually direct them at me.
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.
3) When I close my eyes and think about my past experiences, most of the images that come to mind show me with:
a) People who rarely, if ever, socialise with anyone who is not from the same racial background.
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
c) People who made me feel valued as black person, more so than they do about people from other racial backgrounds
d) People who prefer to be with other people from the same racial background; to the exclusion of people from other racial backgrounds.
4) When I close my eyes and think about my past experiences, most of the images that come to mind show me with:
a) People who value their own individual racial identity, as much as they do, others.
b) People who often make positive statements about the physical bodies of people from different racial backgrounds.
c) People who accept racial difference, and encourage socialising between different racial backgrounds
d) People who accept both the positive and negative aspects of their own physical bodies.
NEXT

Part 4: This questionnaire consists of 18 statements about experience ‘racism’ within the context of your daily life. We are interested in the prevalence of racist incidents in your daily life, and how stressful that may have been for you. Using the drop-down menu, please indicate how often the unfairness in each statement happened to you, and how stressful it was.
1. How many times have you been treated unfairly by teachers and professors because you are black?		How stressful was this for you?
2. How many times have you been treated unfairly by your employers, bosses, and supervisors because you are black?		How stressful was this for you?
3. How many times have you been treated unfairly by your co workers, fellow students, and colleagues, because you are black?		How stressful was this for you?
4. How many times have you been treated unfairly by people in service jobs (store clears, waiters, bartenders, bank tellers and others) because you are black?		How stressful was this for you?
5. How many times have you been treated unfairly by strangers because you are black?		How stressful was this for you?
6. How many times have you been treated unfairly by people in helping jobs (doctors, nurses, psychiatrist, case workers, dentists, schools counsellors, therapists, social workers, and others because you are black?		How stressful was this for you?
7. How many times have you been treated unfairly by neighbours because you are black?		How stressful was this for you?
8. How many times have you been treated unfairly by institutions (schools, universities, law firms, the police, the courts, social services, benefits agencies and others), because you are black?		How stressful was this for you?
9. How many times have you been treated unfairly by people that you thought were your friends because you are black?		How stressful was this for?
10. How many time have you been accused or suspected of doing something wrong (such as stealing, cheating, not doing your share of the work or breaking the law) because you are black?		How stressful was this for?
11. How many times have people misunderstood your intentions and motives because you are black?		How stressful was this for?
12. How many times did you want to tell someone off for being racist but didn’t say anything?		How stressful was this for?
13. How many times have you been really angry about something racist that was done to you?		How stressful was this for?
14. How many times were you forced to take drastic steps (such as filing a grievance, filing a lawsuit, quitting your job, moving away, and other actions) to deal with some racist thing that was done to you?.		How stressful was this for?
15. How many times have you been called a racist name like "nigger", "coon", "jungle bunny", or other names?		How stressful was this for?
16. How many times have you gotten into an argument o a fright about something racist what was done to somebody else?		How stressful was this for?
17. How many times have you been made fun of, picked on pushed, shoved, hit, or threatened with harm because you are black?		How stressful was this for?
18. How different would your life be now if you HAD NOT BEEN treated in a racist and unfair way?		How stressful was this for?
NEXT

Part 5: Please choose the degree to which you agree or disagree with each statement from the drop-down menu. Please respond to ALL statements.
1. I feel that I am a person of worth, at least on an equal basis with others.
2. At times I think I am no good at all
3. I feel that I have a number of good qualities.
4. All in all, I am inclined to feel that I am a failure.
5. I am able to do things as well as most other people.
6. I feel I do not have much to be proud of
7. I take a positive attitude toward myself
8. On the whole, I am satisfied with myself.
9. I wish I could have more respect for myself.
10. I certainly feel useless at times.