Case #______
Sample Questionnaire
Self Esteem Study


Demographics

1) I am (circle one):     m. Male     f. Female

2) My age is ____ years.

3) What is the highest level of education that you have completed? (circle one number)

1    No formal education
2    Some grade school
3    Completed grade school
4    Some high school
5    Completed high school
6    Some college
7    Completed college
8    Some graduate work
9    A graduate degree
4) If you have attended college, what was your most recent major?
____________________________

5) What is your height?    _____feet _____inches

Self-Esteem Scale

(Circle one number for each item indicating your level of agreement.)

6) I feel that Iím a person of worth, at least on an equal basis with others.

1. Strongly disagree     2. Disagree     3. Agree     4. Strongly agree
7) I feel that I have a number of good qualities.
1. Strongly disagree     2. Disagree     3. Agree     4. Strongly agree
8) All in all, I am inclined to feel that I am a failure.
1. Strongly disagree     2. Disagree     3. Agree     4. Strongly agree
9) I am able to do things as well as most other people.
1. Strongly disagree     2. Disagree     3. Agree     4. Strongly agree
10) I feel I do not have much to be proud of.
1. Strongly disagree     2. Disagree     3. Agree     4. Strongly agree


Sample Codebook
Self Esteem Study
VARIABLE NAME FORMAT DESCRIPTION / VARIABLE LABEL / CODED VALUE / VALUE LABEL
CASENO

Numeric
Width = 3
Decimals = 0

Case number
Case number
SEX String
Width = 1
1. I am:

m    Male
f     Female

AGE Numeric
Width = 2
Decimals = 0
2. My age is:
(Code actual age in years.)
EDUC Numeric
Width = 1
Decimals = 0
3. What is the highest level of education that you have completed?
Education level

1    No formal education
2    Some grade school
3    Completed grade school
4    Some high school
5    Completed high school
6    Some college
7    Completed college
8    Some graduate work
9    A graduate degree

MAJOR String
Width = 25
4. If you have attended college, what was your most recent major?
Most recent college major
HT_FEET Numeric
Width = 1
Decimals = 0
5. What is your height?
Height in feet
HT_INCH Numeric
Width = 4
Decimals = 1
5. What is your height?
Height in inches
ESTEEM1 String
Width=1
6. I feel I am a person of worth, at least on an equal basis with others.
I am a person of worth

1 Strongly disagree
2 Disagree
3 Agree
4 Strongly agree
(Use the same codes as above for all ESTEEM items below.)

ESTEEM2 Numeric
Width = 1
Decimals = 0
7. I feel that I have a number of good qualities.
I have good qualities
ESTEEM3 Numeric
Width = 1
Decimals = 0
8. All in all, I am inclined to feel that I am a failure.
I am a failure
(Reverse codes before computing overall self esteem score.)
ESTEEM4 Numeric
Width = 1
Decimals = 0
9. I am able to do things as well as most other people.
I can do things as well
ESTEEM5 Numeric
Width = 1
Decimals = 0
10. I feel I do not have much to be proud of.
I am not proud
(Reverse code before scoring.)

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