Hex 1 Assertiveness Questionnaire
By: Backhaus, Jaimie
Instance of: Assertiveness Questionnaire (7-12)
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Assertiveness is expressing your wants, needs, and thoughts, even when it’s difficult, while respecting others.
1. Express Myself: Are you expressing your feelings clearly? Are you creating and adhering to your boundaries? Strategies include identify communication types, find my feelings, voice my feelings, speak my mind and be kind, respect my boundaries, do my part, and predict outcomes.
2. Respect Others: Are you considering the perspectives of others? Are you communicating respectfully? Strategies include show empathy, listen and summarize, and show respect without words.
The graph provides average ratings for all items within a component, and the table displays the number of students that selected each rating for individual items. In the table, some items, such as “When an argument is over, I often wish I would have said what was really on my mind,” are reverse scored. Selecting a rating of “1—Not Very Like Me” means that students are demonstrating assertiveness, whereas selecting a rating of “5—Very Like Me” means that they may need to focus on assertiveness.
The quiz section shows the correct answer to each knowledge question and the percentage of students that selected the correct answer. Guide students to reflect on the results of this questionnaire and knowledge test to identify ways to continue expanding their learning and practice of assertiveness. Resources for teaching assertiveness are available at www.cccframework.org
| NOT Like Me |
VERY Like Me |
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| Question | Topic | Reversed? | Reverse Corrected Average | #1 Cnt | #2 Cnt | #3 Cnt | #4 Cnt | #5 Cnt |
| 1. I stand up to my friends if they are doing something I don't feel comfortable doing. | Express Myself | NO | 3.5 | 2 | 3 | 4 | 7 | 5 |
| 2. I speak up when someone is not respecting my personal boundaries like 'no cheating off my homework' or 'I don't let friends borrow money.' | Express Myself | NO | 3.8 | 3 | 2 | 2 | 4 | 10 |
| 3. I often have a hard time saying 'No.' | Express Myself | YES | 3 | 4 | 6 | 2 | 4 | 5 |
| 4. I express my opinions, even if others disagree with me. | Express Myself | NO | 4 | 0 | 1 | 8 | 2 | 10 |
| 5. When an argument is over, I often wish I would have said what was really on my mind. | Express Myself | YES | 2 | 1 | 2 | 3 | 4 | 11 |
| 6. I tend to just go along with what everyone else wants instead of stating my own thoughts. | Express Myself | YES | 2.8 | 0 | 4 | 10 | 5 | 2 |
| 7. I sometimes avoid asking questions for fear of sounding stupid. | Express Myself | YES | 2.2 | 1 | 4 | 2 | 6 | 8 |
| 8. I tend to bottle up my emotions rather than talk about my feelings. | Express Myself | YES | 2.2 | 2 | 1 | 5 | 5 | 8 |
| 9. If I disagree with my teacher, I talk to him or her about it. | Express Myself | NO | 2.3 | 7 | 6 | 5 | 1 | 2 |
| 10. If a person has borrowed money (or a game, clothes, or something else of value) and is overdue in returning it, I talk to the person about it. | Express Myself | NO | 3.9 | 1 | 3 | 4 | 3 | 10 |
| 11. I'm usually able to tell people how I'm feeling. | Express Myself | NO | 2.5 | 5 | 6 | 6 | 3 | 1 |
| 12. If I don't like the way someone is being treated, I speak up about it. | Express Myself | NO | 3.9 | 1 | 1 | 3 | 10 | 6 |
| 13. I speak up about things I really care about. | Express Myself | NO | 4.1 | 0 | 1 | 6 | 3 | 11 |
| 14. I am careful to avoid hurting other people's feelings, even when I feel that I have been wronged. | Respect Others | NO | 3.6 | 1 | 2 | 7 | 5 | 6 |
| 15. I have a hard time controlling my emotions when I disagree with someone. | Respect Others | YES | 3.2 | 1 | 9 | 6 | 3 | 2 |
| 16. I avoid attacking someone's intelligence when I disagree with their ideas. | Respect Others | NO | 3.3 | 3 | 3 | 5 | 5 | 5 |
| 17. I listen to other people's opinions, even if I disagree with them. | Respect Others | NO | 4.4 | 0 | 0 | 2 | 9 | 10 |
| 18. In disagreements, I make sure that I understand other points of view. | Respect Others | NO | 3.9 | 1 | 2 | 5 | 4 | 9 |
| 19. In discussions, I communicate that I am listening through body language (nodding my head, avoiding rolling my eyes). | Respect Others | NO | 4 | 1 | 2 | 2 | 6 | 10 |
| 20. Even in an argument, I don't interrupt the other person. | Respect Others | NO | 2.9 | 2 | 4 | 10 | 5 | 0 |
| Total Average With Reverse Questions Flipped | 3.3 OR (57.5%) | |||||||
