St.

Joseph Academy of Valenzuela

#1 San Felipe St., Karuhatan, 1441 Valenzuela city

INFORMED CONSENT OF THE RESPONDENT

I state that I wish to participate in the study. I understand that code numbers will be used to any data

obtained from me to safeguard my privacy. I understand that my participation is voluntary and that I

am free to withdraw at any time, without giving a reason and without cost. Moreover, I am aware

that I am free to ask questions if I feel unsure of the data that I need to disclose.

__________________ ____________________

Signature Date

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 St. Joseph Academy of Valenzuela
#1 San Felipe St., Karuhatan, 1441 Valenzuela city

Name: Date:
Grade level:
Gender Identity:
Sexual Orientation:

Homophobic Victimization (Victim Perspective)

During the past 30 days in your school, how often did the following events happen because you are
perceived to be gay or lesbian?

1, 2 or 3 About once a More than

Never
times week once a week

Someone wrote insulting remarks

   
about me

I was isolated or marginalized    

Negative rumors spread about me    

Someone teased me    

My property was stolen or harmed    

I was physically assaulted (e.g.,

   
being punched or kicked)

Someone touched my private parts    

Someone sent me insulting

messages or contents through

   
electronic medium (e.g., chat

rooms, emails, social networks)

Scoring Instructions

Each item is scored 1 (Never) to 4 (More than once a week).

Each scale is scored by computing the mean item score (sum of the items / number of items).
The scales have a range of 1 to 4. Higher scores indicate greater bullying behavior or reflect more
victimization.

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 St. Joseph Academy of Valenzuela
#1 San Felipe St., Karuhatan, 1441 Valenzuela city

Rosenberg Self-Esteem Scale

Instructions: Below is a list of statements dealing with your general feelings about yourself. If you

strongly agree, circle SA. If you agree with the statement, circle A. If you disagree, circle D. If you

strongly disagree, circle SD.

1. On the whole, I am satisfied with myself. SA A D SD

2. At times, I think I am no good at all. SA A D SD

3. I feel that I have a number of good qualities. SA A D SD

4. I am able to do things as well as most other people. SA A D SD

5. I feel I do not have much to be proud of. SA A D SD

6.I certainly feel useless at times. SA A D SD

7. I feel that I’m a person of worth, at least on an equal plane with others. SA A D SD

8.I wish I could have more respect for myself. SA A D SD

9.All in all, I am inclined to feel that I am a failure. SA A D SD

10. I take a positive attitude toward myself. SA A D SD