INFLUENCE SURVEY
Circle your gender
Male Female
Please circle your grade:
8 9 10 11 12
Circle the number, (1 being not at all, 5 being a lot) that each group of people influences your life and the decisions you make.
Parents:
1 2 3 4 5
Teachers:
1 2 3 4 5
Friends:
1 2 3 4 5
Siblings:
1 2 3 4 5
TV/Movies:
1 2 3 4 5
Celebrities:
1 2 3 4 5
Religious Beliefs:
1 2 3 4 5
WHAT INFLUENCES.....
What clothes you buy:
Price:
1 2 3 4 5
If it's popular:
1 2 3 4 5
Comfort:
1 2 3 4 5
Practicality:
1 2 3 4 5
What you eat:
Taste:
1 2 3 4 5
Appearance:
1 2 3 4 5
Calories:
1 2 3 4 5
Friends:
1 2 3 4 5
What motivates you to get good grades?
a. punishments
b. rewards
c. self fulfillment
d. future aspirations
e. parents
Why are you friends with the people you're friends with?
a. We have activities together
b.We have a lot in common
c. We support eachother in good times and bad
d. We have "history" together
e. Our families are friends
Do you know what you want to be when you grow up?
Yes No
If yes, why?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Circle your gender
Male Female
Please circle your grade:
8 9 10 11 12
Circle the number, (1 being not at all, 5 being a lot) that each group of people influences your life and the decisions you make.
Parents:
1 2 3 4 5
Teachers:
1 2 3 4 5
Friends:
1 2 3 4 5
Siblings:
1 2 3 4 5
TV/Movies:
1 2 3 4 5
Celebrities:
1 2 3 4 5
Religious Beliefs:
1 2 3 4 5
WHAT INFLUENCES.....
What clothes you buy:
Price:
1 2 3 4 5
If it's popular:
1 2 3 4 5
Comfort:
1 2 3 4 5
Practicality:
1 2 3 4 5
What you eat:
Taste:
1 2 3 4 5
Appearance:
1 2 3 4 5
Calories:
1 2 3 4 5
Friends:
1 2 3 4 5
What motivates you to get good grades?
a. punishments
b. rewards
c. self fulfillment
d. future aspirations
e. parents
Why are you friends with the people you're friends with?
a. We have activities together
b.We have a lot in common
c. We support eachother in good times and bad
d. We have "history" together
e. Our families are friends
Do you know what you want to be when you grow up?
Yes No
If yes, why?
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
