Centre for Ethnic Minority Mental Health Part 1: (Please answer ALL questions)
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1. Your Age at last birthday:
2. Your Gender:
3. Your Marital status:
4. How would you define yourself, ethnically?		Black or Black British:
5. What is the highest level of academic qualification you have attained?
6. What is your accessible annual income?
7. Below is a copy of the ‘von Luschan Skin Tone Chart’. This series does not represent all possible skin tones. Can you please indicate which skin tone most represents your own on an unexposed part of your body? 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36


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Part 2: Instructions: Each of the items below describes new situations that people encounter. Some people are concerned about these new situations and others are not. Please imagine yourself in each situation and indicate the number that best indicates how you would feel.
1. Imagine that you are in class one day, and the professor asks a particularly difficult question. A few people, including yourself, raise their hands to answer the question.
a) How concerned/anxious would you be that the professor might not choose you because of your race/ethnicity?
b) I would expect that the professor might not choose me because of my race/ethnicity.
2. Imagine that you are in a pharmacy, trying to pick out a few items. While you’re looking at the different brands, you notice one of the store clerks glancing your way.
a) How concerned /anxious would you be that the clerk might be looking at you because of your race/ethnicity
b) I would expect that the clerk might continue to look at me because of my race/ethnicity.
3. Imagine you have just completed a job interview over the telephone. You are in good spirits because the interviewer seemed enthusiastic about your application. Several days later you complete a second interview in person. Your interviewer informs you that they will let you know about their decision soon.
a) How concerned/anxious would you be that you might not be hired because of your race/ethnicity?
b) I would expect that I might not be hired because of my race/ethnicity.
4. It’s late at night and you are driving down a country road you’re not familiar with. Luckily, there is a 24-hour 7-11 just ahead, so you stop there and head up to the counter to ask the young woman for directions.
a) How concerned/anxious would you be that she might not help you because of your race/ethnicity?
b) I would expect that the woman might not help me because of my race/ethnicity.
5. Imagine that a new school counsellor is selecting students for a summer scholarship fund that you really want. The counsellor has only one scholarship left and you are one of several students that is eligible for this scholarship.
a) How concerned/anxious would you be that the counsellor might not choose you because of your race/ethnicity?
b) I would expect that the woman might not help me because of my race/ethnicity.
6. Imagine you have just finished shopping, and you are leaving the store carrying several bags. It’s closing time, and several people are filing out of the store at once. Suddenly, the alarm begins to sound, and a security guard comes over to investigate.
a) How concerned/anxious would you be that the guard might stop you because of your race/ethnicity?
b) I would expect that the woman might not help me because of my race/ethnicity.
7. Imagine you are riding the bus one day. The bus is full except for two seats, one of which is next to you. As the bus comes to the next stop, you notice a woman getting on the bus.
a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity?
b) I would expect that the woman might not help me because of my race/ethnicity.
8. Imagine that you are in a restaurant, trying to get the attention of your waitress. A lot of other people are trying to get her attention as well.
a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity?
b) I would expect that the guard might stop me because of my race/ethnicity.
9. Imagine you’re driving down the street, and there is a police barricade just ahead. The police officers are randomly pulling people over to check drivers’ licenses and registrations.
a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity?
b) I would expect that the guard might stop me because of my race/ethnicity.
10. Imagine that it’s the second day of your new class. The teacher assigned a writing sample yesterday and today the teacher announces that she has finished correcting the papers. You wait for your paper to be returned.
a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity?
b) I would expect that the guard might stop me because of my race/ethnicity.
11. Imagine that you are standing in line for the ATM machine, and you notice the woman at the machine glances back while she’s getting her money.
a) How concerned/anxious would you be that she might avoid sitting next to you because of your race/ethnicity?
b) I would expect that the guard might stop me because of my race/ethnicity.
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Part 3 : Instructions: This questionnaire assesses concerns about physical appearance. Please read each question carefully and check the answer that best describes your experience. Also write in answers where indicated.
1. Do other people appear concerned about the appearance of some part of your body, which they consider especially unattractive?
2. What do think these concerns are? What specifically bothers them about the appearance of these body parts?
3. If, they are at least somewhat concerned, do these concerns preoccupy you? That is, you think about them a lot and they’re hard to stop thinking about? (Check the best answer )
4. What effect has their preoccupation with your physical appearance had on your life? Please describe):
5. Does their behaviour towards you often caused you a lot of distress, torment or pain? How much? (Please check the best answer)
6. Has other people’s apparent concern with your physical appearance significantly interfered with your relationships at home, school, college, work, or your ability tio function in your role or other important areas of your life? And if so how much? (Please check the best answer)
7. Do you ever avoid things because of your physical other people's preoccupation with your appearance? How much? (Please check the best answer).
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Part 4: Instructions: This part of the questionnaire looks at how you represent relationships within your own mind. Please read each statement carefully, and highlight the answer that best describes your experience.
1) When I close my eyes and think about my past experiences, most of the images that come to mind are of me with:
a) ) People who make racist comments about other black people, but it’s not serious, and it doesn’t involve me.
b) People who make insulting remarks about other black people, but they always make a point of excluding me:
c) People who never mention the colour of my skin, my hair texture, or the thickness of my lips, but I know they have a significant effect on how they respond to me:
d) People like to socialise with me, but they wouldn’t want other people like me to have a personal relationship with any member of their families:
2) When I close my eyes and think about my past experiences, most of the images that come to mind of me with:
a) People who make racist remarks about some aspect of my black body.
b) People who tell me how much they don't like the darkness of my skin colour, my lips or texture of texture:
c) People who make racist jokes, and usually direct them at me.
d) People who say insulting things about my skin colour, shape of my nose, or the thickness of my lips, and don’t seem to care if it makes me feel unwanted and unhappy.
3) When I close my eyes and think about my past experiences, most of the images that come to mind show me with:
a) People who rarely, if ever, socialise with anyone who is not from the same racial background.
b) People who often make more positive remarks about the colour of my skin, the shape of my nose, texture of my hair, or thickness of my lips, than they do people from other racial backgrounds
c) People who made me feel valued as black person, more so than they do about people from other racial backgrounds
d) People who prefer to be with other people from the same racial background; to the exclusion of people from other racial backgrounds.
4) When I close my eyes and think about my past experiences, most of the images that come to mind show me with:
a) People who value their own individual racial identity, as much as they do, others.
b) People who often make positive statements about the physical bodies of people from different racial backgrounds.
c) People who accept racial difference, and encourage socialising between different racial backgrounds
d) People who accept both the positive and negative aspects of their own physical bodies.
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Part 5: This questionnaire consists of 15 statements about experiences that you may have in your daily life. We are interested in the strength of your agreement with these statements; when you are not under the influence of alcohol or drugs. (Using the drop-down menu, indicate to what extent you agree or disgree with the statement)
1. There are things I prefer not to think about:
2. Sometimes, I wonder why I have the thoughts I do.
3. I have thoughts that I can not stop.
4. There are images that come to mind that I can not erase.
5. My thoughts frequently return to one idea.
6. I wish I could stop thinking of certain things..
7. Sometimes my mind races so fast I wish I could stop it.
8. I always try to put problems out of mind.
9. There are thoughts that keep jumping into my head.
10. Sometimes, I stay busy just to keep thoughts from intruding on my mind.
11. There are things that I try not to think about.
12. Sometimes, I stay bust just to keep thoughts from intruding on my mind.
13. I often do things to distract myself from my thoughts.
14. I often have thoughts that I try to avoid.
15. There are many thoughts that I have that I don’t tell anyone.
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Part 6: This questionnaire consists of 18 statements about experience ‘racism’ within the context of your daily life. We are interested in the prevalence of racist incidents in your daily life, and how stressful that may have been for you. Using the drop-down menu, please indicate how often the unfairness in each statement happened to you, and how stressful it was.
1. How many times have you been treated unfairly by teachers and professors because you are black?	How stressful was this for you?
2. How many times have you been treated unfairly by your employers, bosses, and supervisors because you are black?	How stressful was this for you?
3. How many times have you been treated unfairly by your co workers, fellow students, and colleagues, because you are black?	How stressful was this for you?
4. How many times have you been treated unfairly by people in service jobs (store clears, waiters, bartenders, bank tellers and others) because you are black?	How stressful was this for you?
5. How many times have you been treated unfairly by strangers because you are black?	How stressful was this for you?
6. How many times have you been treated unfairly by people in helping jobs (doctors, nurses, psychiatrist, case workers, dentists, schools counsellors, therapists, social workers, and others because you are black?	How stressful was this for you?
7. How many times have you been treated unfairly by neighbours because you are black?	How stressful was this for you?
8. How many times have you been treated unfairly by institutions (schools, universities, law firms, the police, the courts, social services, benefits agencies and others), because you are black?	How stressful was this for you?
9. How many times have you been treated unfairly by people that you thought were your friends because you are black?	How stressful was this for?
10. How many time have you been accused or suspected of doing something wrong (such as stealing, cheating, not doing your share of the work or breaking the law) because you are black?	How stressful was this for?
11. How many times have people misunderstood your intentions and motives because you are black?	How stressful was this for?
12. How many times did you want to tell someone off for being racist but didn’t say anything?	How stressful was this for?
13. How many times have you been really angry about something racist that was done to you?