Survey Sample: PSAP 

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Preparing for Success After Prison (PSAP) Program Survey

Background Information (Pre-Survey Only)

  1. Age: _____
  1. Which of the following best describes you?

☐ Hispanic or Latino ☐ American Indian or Native American 

☐ Black of African-American ☐ White and Non-Latino 

☐ Asian ☐ Other (Please Specify _________________________________) 

  1. What was your marital status prior to your incarceration (select one)?

☐ Never married ☐ Separated

☐ Living together ☐ Divorced

☐ Legally married ☐ Widowed

  1. What is your highest level of education (select one)?

☐ No High School ☐ Vocational certificate

☐ Some High School ☐ Some college

☐ High School Diploma ☐ Associate’s degree/Bachelor’s degree

☐ GED ☐ Master’s degree/doctorate degree

  1. If high school graduate, did you obtain your degree or GED in prison?

☐ Yes ☐ No ☐ Not applicable

  1. If any college, did you attend or obtain a degree in prison?

☐ Yes ☐ No ☐ Not applicable

  1. How many TIMES during your life have you been arrested? ___________ #ARRESTS
  1. How many TIMES during your life have you been arrested before the age of 18? ___________ #ARRESTS
  1. How many times have you been arrested for a property offense? ____________
  1. How many times have you been arrested for a violent offense? ____________
  1. How many times have you been arrested for a drug offense? ___________
  1. How many times have you been arrested for a sex offense? __________

SECTION A: Please indicate the extent to which you agree or disagree with the statements in this section 

Please answer all of the questions and remember that there are no right or wrong answers. When answering the questions, think about how you feel today.

1.I have close friends I can trust.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
2.I don’t really think about what I’m doing, I just do it.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
3.There are people who really understand me.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
4.My problems will dominate all of my life.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
5.I often do the first thing that comes into my head.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
6.There are people I can turn to when I have a problem.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
7.I tend to bounce back quickly after hard times.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
8.I make good decisions.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
9.I feel confident.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
10.I feel hopeless about my future.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
11.There are some people who I trust.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
12.I feel good about myself.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
13.I feel capable of making decisions.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
14.I have a hard time making it through stressful events.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
15.I owe it to myself to change.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
16.My life is full of problems which I can’t overcome.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
17.Anyone can talk about changing themselves; I’m actually going to do something about it.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
18.I often do things without thinking of the consequences.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
19.I usually deal with problems well.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
20.I am confident that I can cope with unexpected events.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree
21.I am really working hard to change my life.Strongly agreeAgreeNeither agree nor disagreeDisagreeStrongly disagree

                 Section B: Using a scale from 0 to 4, please indicate how well each item describes you. 

 Does not describe me very well (0)      (1)      (2)     (3)  Describes me very well  (4) 
1. I sometimes try to understand my friends better by imagining how things look from their point of view.  [   ] [   ] [   ] [   ] [   ] 
2. I sometimes find it difficult to see things from the “other person’s” point of view.  [   ] [   ] [   ] [   ] [   ] 
3. Sometimes I don’t feel very sorry for other people when they are having problems.  [   ] [   ] [   ] [   ] [   ] 
4. I try to look at everybody’s side of a disagreement before I make a decision.  [   ] [   ] [   ] [   ] [   ] 
5. When I see someone being taken advantage of, I feel kind of protective towards him/her.  [   ] [   ] [   ] [   ] [   ] 
6. I often have tender, concerned feelings for people less fortunate than me.  [   ] [   ] [   ] [   ] [   ] 
7. Other people’s misfortunes do not usually disturb me a great deal.  [   ] [   ] [   ] [   ] [   ] 
8. If I’m sure I’m right about something, I don’t waste much time listening to other people’s arguments.  [   ] [   ] [   ] [   ] [   ] 
9. When I see someone being treated unfairly, I sometimes don’t feel sorry for them.  [   ] [   ] [   ] [   ] [   ] 
10. I am often quite touched by things that I see happen. [   ] [   ] [   ] [   ] [   ] 
11. I believe that there are two sides to every question and try to look at them both.  [   ] [   ] [   ] [   ] [   ] 
12. I would describe myself as a soft-hearted person.  [   ] [   ] [   ] [   ] [   ] 
13. When I’m upset at someone, I usually try to “put myself in his/her shoes” for a while.  [   ] [   ] [   ] [   ] [   ] 
14. Before criticizing somebody, I try to imagine how I would feel if I were in their place. [   ] [   ] [   ] [   ] [   ]

Section C: Using a scale from 1 to 5, please indicate the extent to which you agree with the following statements.

 Strongly disagree
(1
Disagree

(2
   Neither disagree or agree(3Agree  
(4)  
Strongly agree (5
1.  I know when to speak about my personal problems to others[   ] [   ] [   ] [   ] [   ] 
2.  When I am faced with obstacles, I remember times I faced similar obstacles and overcame them [   ] [   ] [   ] [   ] [   ] 
3.  I expect that I will do well on most things I try [   ] [   ] [   ] [   ] [   ] 
4.  Other people find it easy to confide in me [   ] [   ] [   ] [   ] [   ] 
5.  I find it hard to understand the non-verbal messages of other people* [   ] [   ] [   ] [   ] [   ] 
6.  Some of the major events of my life have led me to re-evaluate what is important and not important [   ] [   ] [   ] [   ] [   ] 
7.   When my mood changes, I see new possibilities[   ] [   ] [   ] [   ] [   ] 
8.  Emotions are one of the things that make my life worth living [   ] [   ] [   ] [   ] [   ] 
9.   I am aware of my emotions as I experience them [   ] [   ] [   ] [   ] [   ] 
10. I expect good things to happen[   ] [   ] [   ] [   ] [   ] 
11. I like to share my emotions with others [   ] [   ] [   ] [   ] [   ] 
12. When I experience a positive emotion, I know how to make it last[   ] [   ] [   ] [   ] [   ] 
13.  I arrange events others enjoy  [   ] [   ] [   ] [   ] [   ] 
14. I seek out activities that make me happy[   ] [   ] [   ] [   ] [   ]
15. I am aware of the non-verbal messages I send to others[   ] [   ] [   ] [   ] [   ]
16. I present myself in a way that makes a good impression on others[   ] [   ] [   ] [   ] [   ]
17. When I am in a positive mood, solving problems is easy for me[   ] [   ] [   ] [   ] [   ]
18. By looking at their facial expressions, I recognize the emotions people are experiencing[   ] [   ] [   ] [   ] [   ]
19. I know why my emotions change[   ] [   ] [   ] [   ] [   ]
20. When I am in a positive mood, I am able to come up with new ideas[   ] [   ] [   ] [   ] [   ]
21. I have control over my emotions[   ] [   ] [   ] [   ] [   ]
22. I easily recognize my emotions as I experience them[   ] [   ] [   ] [   ] [   ]
23. I motivate myself by imagining a good outcome to tasks I take on[   ] [   ] [   ] [   ] [   ]
24. I compliment others when they have done something well[   ] [   ] [   ] [   ] [   ]
25. I am aware of the non-verbal messages other people send[   ] [   ] [   ] [   ] [   ]
26. When another person tells me about an important event in his or her life, I almost feel as though I have experienced this event myself[   ] [   ] [   ] [   ] [   ]
27. When I feel a change in emotions, I tend to come up with new ideas[   ] [   ] [   ] [   ] [   ]
28. When I am faced with a challenge, I give up because I believe I will fail*[   ] [   ] [   ] [   ] [   ]
29. I know what other people are feeling just by looking at them[   ] [   ] [   ] [   ] [   ]
30. I help other people feel better when they are down[   ] [   ] [   ] [   ] [   ]
31. I use good moods to help myself keep trying in the face of obstacles[   ] [   ] [   ] [   ] [   ]
32. I can tell how people are feeling by listening to the tone of their voice[   ] [   ] [   ] [   ] [   ]
33. It is difficult for me to understand why people feel the way they do*[   ] [   ] [   ] [   ] [   ]

PSAP Participant Feedback Questions (Post-Survey Only)

  1. On a scale of 1 to 10, with 1 being “Very Poor,” and 10 being “Excellent,” how would you rate this program?

                        1 2 3 4 5 6 7 8 9 10

                 Very Poor                           Excellent

2.  Why did you give this rating?

3. Please tell us how this program has impacted you?

4.  What did you like best about this program and why?

5. What did you like least about this program and why?

6. Do you have any recommendations on how this program can be improved?

7.  Please provide any additional feedback here.

Program Participation (Post-Survey Only)

What other programs have you participated in since starting the PSAP Program?

 Name of Program Completed? (circle one)

____________________________________________               YES                   NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

____________________________________________               YES                    NO

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