ASSERTIVENESS QUESTIONNAIREASSERTIVENESS QUESTIONNAIRE INSTRUCTIONS: circle the correct numbers beside each item. 1 = no discomfort 1 = always do it 2 = a little discomfort 2 = usually do it 3 = a fair amount of discomfort 3 = sometimes do it 4 = much discomfort 4 = rarely do it 5 = very much discomfort 5 = never do it DEGREE OF HOW OFTEN DISCOMFORT SITUATION YOU DO IT very none much always never1 2 3 4 5 1. Turn down a friend's request to borrow a 1 2 3 4 5 favorite item like clothing, jewelry, stereo, etc. 1 2 3 4 5 2. Compliment a friend. 1 2 3 4 5 1 2 3 4 5 3. Ask a favor of someone. 1 2 3 4 5 1 2 3 4 5 4. Resist sales pressure. 1 2 3 4 5 1 2 3 4 5 5. Apologize when you are at fault. 1 2 3 4 5 1 2 3 4 5 6. Turn down a request for a meeting or date. 1 2 3 4 5 1 2 3 4 5 7. Admit fear and ask for consideration 1 2 3 4 5 1 2 3 4 5 8. Tell a close friend when he/she says or does 1 2 3 4 5 something that bothers you. 1 2 3 4 5 9. Ask for a raise. 1 2 3 4 5 1 2 3 4 5 10. Admit ignorance in some area. 1 2 3 4 5 1 2 3 4 5 11. Turn down a request to borrow money. 1 2 3 4 5 1 2 3 4 5 12. Ask a personal question. 1 2 3 4 5 1 2 3 4 5 13. Turn off a talkative friend. 1 2 3 4 5 1 2 3 4 5 14. Ask for constructive criticism. 1 2 3 4 5 1 2 3 4 5 15. Initiate a conversation with someone you don't know. 1 2 3 4 5 1 2 3 4 5 16. Compliment a person close to you. 1 2 3 4 5 1 2 3 4 5 17. Request a meeting or date with someone. 1 2 3 4 5 1 2 3 4 5 18. Request a meeting after being turned down once. 1 2 3 4 5 1 2 3 4 5 19. Admit confusion in a discussion and ask clarification. 1 2 3 4 5 1 2 3 4 5 20. Apply for a job. 1 2 3 4 5 1 2 3 4 5 21. Ask whether you have offended someone. 1 2 3 4 5ASSERTIVENESS QUESTIONNAIRE [page 2] DEGREE OF HOW OFTEN DISCOMFORT SITUATION YOU DO IT very none much always never1 2 3 4 5 22. Tell someone that you like him or her. 1 2 3 4 5 1 2 3 4 5 23. Request expected service when it is not given 1 2 3 4 5 (such as in a restaurant). 1 2 3 4 5 1 2 3 4 5 24. Discuss openly with a person his/her criticism of you 1 2 3 4 5 1 2 3 4 5 25. Return a defective item at a store or food 1 2 3 4 5 at a restaurant. 1 2 3 4 5 1 2 3 4 5 26. Express an opinion different from that of the 1 2 3 4 5 person you are talking to. 1 2 3 4 5 1 2 3 4 5 27. Resist sexual overtures when you are not interested. 1 2 3 4 5 1 2 3 4 5 28. Tell a person when you feel he or she did something unfair to you. 1 2 3 4 5 1 2 3 4 5 29. Accept a date. 1 2 3 4 5 1 2 3 4 5 30. Tell someone good news about yourself. 1 2 3 4 5 1 2 3 4 5 31. Resist pressure to drink when you don't want to. 1 2 3 4 5 1 2 3 4 5 32. Resist an unfair demand by someone close to you. 1 2 3 4 5 1 2 3 4 5 33. Quit a job, club, or social group. 1 2 3 4 5 1 2 3 4 5 34. Resist pressure to use drugs when you don't want to. 1 2 3 4 5 1 2 3 4 5 35. Discuss openly with a person his/her criticism 1 2 3 4 5 of your work. 1 2 3 4 5 36. Request the return of a borrowed item. 1 2 3 4 5 1 2 3 4 5 37. Receive compliments. 1 2 3 4 5 1 2 3 4 5 38. Continue to converse with someone who disagrees 1 2 3 4 5 with you. 1 2 3 4 5 1 2 3 4 5 39. Tell a friend or fellow student when he/she says or does something that bothers you. 1 2 3 4 5 1 2 3 4 5 40. Ask a person who is annoying you in a public 1 2 3 4 5 situation to stop. questionnaire developed by Walter vom Saal based on earlier survey
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