Name: Age:

Gender:

Direction: Check one box for each statement below to show.

Survey scale: 1 = never 2= seldom 3=

sometimes

4= often 5= always

Construct: How does stereotype strongly affects you?

Question 1 2 3 4 5

1. I am afraid to express my ideas

even though I have one.

2. I am afraid to go outside the

house or attend school

activities.

3. I am afraid to join any

extracurricular activities.

4. I don’t have the courage to

socialize with normal people.

5. I am always anxious about the

outcome of my performances.

Total score: +6
Participant Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10
1 3 2 4 3 2 5 2 3 5 4
2 2 3 5 4 3 3 5 3 4 5
3 3 4 3 5 3 5 4 3 5 4
4 5 3 5 3 4 3 5 3 4 5
5 3 5 4 3 4 5 3 5 4 3
6 3 5 4 3 4 5 3 4 3 5
7 5 3 4 2 5 3 4 3 4 3
8 3 5 4 3 4 3 5 3 5 4
9 5 3 3 3 5 3 5 4 3 5
10 3 5 4 5 3 4 3 5 4 5