Age: ____ Gender (circle one): M F Prefer not to say
Race: ( ) Non-Mixed ( ) Mixed
Please specify*: ___________________________________________________
1. How would you describe the way you were raised?
a. My parents were too strict
b. My parents were reasonable but I have some bad memories
c. I think they did a good job
d. I could duck out of a few things but they didn’t turn a blind eye all the time
e. I sometimes feel they were too lenient
2. Have you witnessed conflict within your family (i.e. immediate vs. extended family OR just between immediate family)?
a. Yes, sometimes it really got to me
b. Yes, but it wasn’t a big deal
c. Sometimes.
d. No, we got along pretty well.
3. If yes to the above: What were the fights most often about?
¨ The Children (e.g. disciplining them, raising them, keeping them in touch with their roots, dealing with discrimination, etc.)
¨ Culture, Religion (e.g. customs/traditions, etc.)
¨ Clothing (e.g. modesty, traditions, etc.)
¨ Entertainment (e.g. appropriateness, culture, etc.)
¨ Finances
¨ Other, please specify: ____________________________________________
4. Have you witnessed conflict between your parents?
a. Yes, sometimes it really got to me
b. Yes, but it wasn’t a big deal
c. Sometimes.
d. No, they got along pretty well.
5. If yes to the above: What were the fights most often about?
¨ The Children (e.g. disciplining them, raising them, keeping them in touch with their roots, dealing with discrimination, etc.)
¨ Culture, Religion (e.g. customs/traditions, etc.)
¨ Clothing (e.g. modesty, traditions, etc.)
¨ Entertainment (e.g. age-appropriateness, sensitivity, culture, etc.)
¨ Finances
¨ Other, please specify: ____________________________________________
Part B: Your Surroundings
6. Were you or anyone you knew ever provoked, targeted, or teased in relation to your racial background or appearance?
a. Yes b. No
7. Please select all that most closely describe what occurred:
¨ Physical Contact (e.g., pushing, shoving, kicking, poking, hip-checking, unauthorized touching, etc.)
¨ Physical Mocking (e.g., making faces, rude gestures, mimicry, etc.)
¨ Verbal Abuse (e.g., name-calling, inappropriate jokes or comments, allusions, mockery of speech, etc.)
¨ Exclusion/Avoidance (e.g., from social activities, choosing the victim last, ignoring the victim, etc.)
¨ Other, please describe: ____________________________________________
8. Have you ever felt you were treated differently because of your race?
a. Yes, mostly positively.
b. Yes, mostly negatively.
c. No.
9. Are most of your peers from one race (or a few similar races)?
a. Yes b. No
10. How does the way you were raised compare with how your peers were raised?
a. My parents were too strict
b. My parents were too lenient
c. My parents were more or less the same as my peers’
d. There were some differences, but it wasn’t a big deal
e. I wish I were raised the way my friends were
11. Have you ever felt disconnected from your family roots?
a. Often
b. Sometimes
c. No
12. Why or why not?
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13. Do you ever feel like you have to do something to “fit in”?
a. Yes b. No
If yes, what do you do?
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14. Is there a particular celebrity of similar race to you that you look up to?
a. Yes b. No
If yes, who is it?
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15. Is there a particular celebrity of a different race from you that you look up to?
a. Yes b. No
If yes, who is it?
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16. Do you feel that interracial relationships should be celebrated? Why or why not?
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17. Do you feel that people of mixed race are more likely to be successful than the average populace? Why or why not?
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