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ysr ASEBA (1)

The document is a Youth Self-Report form designed for individuals aged 11-18 to provide personal information, including their name, gender, age, and parents' occupations. It includes sections for listing favorite sports, hobbies, organizations, and jobs, along with self-assessment questions comparing their activities and performance to peers. The form encourages honest responses and allows for additional comments.

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Leticia MP
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151 views4 pages

ysr ASEBA (1)

The document is a Youth Self-Report form designed for individuals aged 11-18 to provide personal information, including their name, gender, age, and parents' occupations. It includes sections for listing favorite sports, hobbies, organizations, and jobs, along with self-assessment questions comparing their activities and performance to peers. The form encourages honest responses and allows for additional comments.

Uploaded by

Leticia MP
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

Please print YOUTH SELF-REPORT FOR AGES 11-18 For office use only

ID #
YOUR First Middle Last PARENTS’ USUAL TYPE OF WORK, even if not working now.
FULL (Please be specific — for example, auto mechanic, high school teacher,
NAME homemaker, laborer, lathe operator, shoe salesman, army sergeant.)
YOUR GENDER YOUR AGE YOUR ETHNIC GROUP PARENT 1
Boy Girl OR RACE (or father) __________________________________

TODAY’S DATE YOUR BIRTHDATE PARENT 2


Mo. Date Yr. Mo. Date Yr. (or mother) __________________________________

GRADE IN IF YOU ARE WORKING, PLEASE


SCHOOL STATE YOUR TYPE OF WORK: Please fill out this form to reflect your views, even if other
people might not agree. Feel free to print additional comments
_____________________________ beside each item and in the spaces provided on pages 2 and
NOT ATTENDING
SCHOOL
4. Be sure to answer all items.
_____________________________

I. Please list the sports you most like Compared to others of your age, Compared to others of your age,
to take part in. For example: swimming, about how much time do you how well do you do each one?
baseball, skating, skate boarding, bike spend in each?
riding, fishing, etc. Less More
Than Than Below Above
None Average Average Average Average Average Average
a.

b.

c.

II. Please list your favorite hobbies, Compared to others of your age, Compared to others of your age,
activities, and games, other than sports. about how much time do you how well do you do each one?
For example: video games, cards, reading, spend in each?
piano, cars, computers, crafts, etc. (Do not
include listening to radio, watching TV, or
other media.) Less More
Than Than Below Above
None Average Average Average Average Average Average

a.

b.

c.

III. Please list any organizations, clubs, Compared to others of your age,
teams, or groups you belong to. how active are you in each?
Less More
None Active Average Active

a.

b.

c.

IV. Please list any jobs or chores you have. Compared to others of your age,
For example: doing dishes, babysitting, how well do you carry them out?
making bed, working in store, etc. (Include
both paid and unpaid jobs and chores.)
Below Above
None Average Average Average
a.

b.
Be sure you answered all
c.
items. Then see other side.

Copyright 2001 T. Achenbach UNAUTHORIZED COPYING IS ILLEGAL 6-1-01 Edition - 501


ASEBA, University of Vermont 5/2015 Version
1 South Prospect St., Burlington, VT 05401-3456
www.ASEBA.org PAGE 1
81945_CBCL_501 4/9/09 9:14 AM Page 2
81945_CBCL_501 4/9/09 9:14 AM Page 3
81945_CBCL_501 4/9/09 9:14 AM Page 4

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