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pdfBy Maria Kovacs, Ph.D.
Self-Report
Short
Name/ID:_________________________________________________
Date of Birth:_ ______ /_______/_______
Age:_______
Today’s Date:_ ______ /_______/_______
Grade:_______
Sex:
Male
Female
Year
Year
Month
Day
Month
Kids sometimes have different feelings and ideas.
Here is an example of how this form works.
Try it. Put a mark next to the sentence that
describes you best.
Example:
I read books all the time.
I read books once in a while.
I never read books.
e
This form lists the feelings and ideas in groups. From each
group of three sentences, pick one sentence that describes
you best for the past two weeks. After you pick a sentence
from the first group, go on to the next group.
m
pl
There is no right or wrong answer. Just pick the sentence
that best describes the way you have been recently. Put a
next to your answer. Put the mark in the
mark like this
box next to the sentence that you pick.
Sa
Remember, for each group, pick out the sentence that describes you best in the past two weeks.
Item 1
I am sad once in a while.
I am sad many times.
I am sad all the time.
Item 7
I feel cranky all the time.
I feel cranky many times.
I am almost never cranky.
Item 2
Nothing will ever work out for me.
I am not sure if things will work out for me.
Things will work out for me O.K.
Item 8
I cannot make up my mind about things.
It is hard to make up my mind about things.
I make up my mind about things easily.
Item 3
I do most things O.K.
I do many things wrong.
I do everything wrong.
Item 9
I have to push myself all the time to do my schoolwork.
I have to push myself many times to do my schoolwork.
Doing schoolwork is not a big problem.
Item 4
I have fun in many things.
I have fun in some things.
Nothing is fun at all.
Item 10
I am tired once in a while.
I am tired many days.
I am tired all the time.
Item 5
I am important to my family.
I am not sure if I am important to my family.
My family is better off without me.
Item 11
Most days I do not feel like eating.
Many days I do not feel like eating.
I eat pretty well.
Item 6
I hate myself.
I do not like myself.
I like myself.
Item 12
I do not feel alone.
I feel alone many times.
I feel alone all the time.
Copyright © 2011 Maria Kovacs, Ph.D. and Multi-Health Systems Inc. All rights reserved.
In the United States, P.O. Box 950, North Tonawanda, NY 14120-0950, 1-800-456-3003. In Canada, 3770 Victoria Park Avenue, Toronto, ON M2H 3M6,
1-800-268-6011, 1-416-492-2627, Fax 1-416-492-3343. Internationally, +1-416-492-2627. Fax, +1-416-492-3343 or (888) 540-4484.
By Maria Kovacs, Ph.D.
Self-Report Short
Scoring Page
Name/ID:_________________________________________________
Date of Birth:_ ______ /_______/_______
Age:_______
Today’s Date:_ ______ /_______/_______
Grade:_______
Sex:
Male
Female
Circle one
Year
Year
Month
Month
1. Make sure only one box is marked for each item.
3. Write the sum in the Total Raw Score box.
pl
2. Add the numbers next to all checked boxes.
e
Instructions:
Item 1
0
1
2
Sa
m
4. Transfer the value to the Profile Form on the next page.
Item 7
2
1
0
Item 2
2
1
0
Item 8
2
1
0
Item 3
0
1
2
Item 9
2
1
0
Item 4
0
1
2
Item 10
0
1
2
Item 5
0
1
2
Item 11
2
1
0
Item 6
2
1
0
Item 12
0
1
2
TOTAL RAW SCORE
Copyright © 2011 Maria Kovacs, Ph.D. and Multi-Health Systems Inc. All rights reserved.
In the United States, P.O. Box 950, North Tonawanda, NY 14120-0950, 1-800-456-3003. In Canada, 3770 Victoria Park Avenue, Toronto, ON M2H 3M6,
1-800-268-6011, 1-416-492-2627, Fax 1-416-492-3343. Internationally, +1-416-492-2627. Fax, +1-416-492-3343 or (888) 540-4484.
Day
Day
By Maria Kovacs, Ph.D.
Self-Report Short
Profile
Name/ID:_________________________________________________
Date of Birth:_ ______ /_______/_______
Age:_______
Today’s Date:_ ______ /_______/_______
Grade:_______
Sex:
Male
Year
Female
Circle one
Year
Month
Month
Instructions:
1. Circle the Total Raw Score from the Scoring Page under the appropriate sex and age column.
2. Follow the row across to find the corresponding T-score and classification.
3. Transfer the T-score to the box on the bottom of the page.
7–12
13–17
13+
19+
89
18
88
87
12
86
84
83
11
79
78
77
76
75
Sa
80
15
15+
15+
90+
14
88
89
87
86
13
13
83
82
12
12
Very Elevated
79
11
11
76
9
75
10
10
72
8
9
9
70
69
68
68
Elevated
7
8
8
10
66
65
9
64
7
7
6
8
61
62
6
5
61
6
59
58
5
57
4
5
6
55
4
54
5
53
54
4
3
51
4
50
49
2
Average or Lower
3
3
48
2
47
2
46
2
45
1
46
45
1
1
43
50
49
3
47
44
1
42
43
42
41
≤40
53
52
51
44
57
56
55
48
60
59
7
58
52
64
63
High Average
62
56
67
66
65
60
71
70
11
69
63
74
73
12
72
67
78
77
73
71
81
80
14
13
85
84
10
74
T
13–17
16
82
81
Males
7–12
14
m
17
85
Classification
e
90+
Total
Females
pl
T
41
0
0
0
0
≤40
T=
Copyright © 2011 Maria Kovacs, Ph.D. and Multi-Health Systems Inc. All rights reserved.
In the United States, P.O. Box 950, North Tonawanda, NY 14120-0950, 1-800-456-3003. In Canada, 3770 Victoria Park Avenue, Toronto, ON M2H 3M6,
1-800-268-6011, 1-416-492-2627, Fax 1-416-492-3343. Internationally, +1-416-492-2627. Fax, +1-416-492-3343 or (888) 540-4484.
Day
Day
| File Type | application/pdf |
| File Modified | 2010-11-08 |
| File Created | 2010-11-02 |