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Daily Diary Record Sheet
    
  ID#: 
    
Date: 
          -- mm/dd/yy
Instructions:        
Please answer these questions at the end of the day each Monday and Wednesday, when you do not expect to have any more social interactions.

In answering the questions, please consider only what happened to you today or yesterday.
For each of the interactions or events you describe below in Section A and Section B, please provide a rating of how positive or negative it was, using the following scale:
1
2
3
4
5
Extremely
Negative
Moderately
Negative
Neutral
Moderately
Positive
Extremely
Positive
         
For each of the interactions or events you describe below in Section A and Section B, please provide a rating of how important or meaningful it was to you, using the following scale:
1
2
3
4
5
Not at all
Important
 
Moderately
Important
 
Extremely
Important
Section A:
Did you have any interactions with anyone today or yesterday that made you feel confident or good about your own abilities and/or potential? Please list the people with whom you had these interactions. Do not list these people by name, but by their role in your life (e.g., teacher, mother, friend, boyfriend/girlfriend).
a1 a4     
    
a2 a5     
    
a3 a6     
    
For the two most important of these interactions, use the table below to give a brief description of the interaction. The first row contains an example.
Who was the
person?
Describe the interaction
Posivity
rating*
Importance
rating**
Why was it important?
What impact did it have on you?
 Example:
   Mother
 Talked to her on the phone about school
 4*
 5**
 She made me feel that she believed in me  I decided not to drop my biology class
    
 
   
    
   
  *Positivity Scale    1(extremely negative)      2(moderately negative)   3(Neutral)   4(Moderately positive)   5(Extremely positive)
 **Importance Scale 1(not at all important)     2                                   3(Moderately Important)        4        5(Extremely important)
Were there any other significant events (not social interactions) that made you think positively about your own abilities and/or potential? Examples may be hearing someone make a comment in class, seeing something on television, reading something, receiving a test grade, learning important news about one of your friends or family members. Use the table below to list and describe these these events.
Describe the Event
Positivity
Importance
Why was it important?
What impact did it have on you?
Example:
Watched a TV program about lawyers
5*
4**
It made me realize how interesting it might be to practice law. I might investigate what it would take to get into law school.
  *Positivity Scale    1(extremely negative)      2(moderately negative)   3(Neutral)   4(Moderately positive)   5(Extremely positive)
 **Importance Scale 1(not at all important)     2                                   3(Moderately Important)        4        5(Extremely important)

Did any of these interactions or events make you feel as if some thing might be possible for you to do that you had considered impossible before?  Yes   No
Please explain:

 
Section B:
Did you have any interactions with anyone today or yesterday that made you feel doubtful or insecure about your own abilities and/or potential? Please list the people with whom you had these interactions. Do not list these people by name, but by their role in your life (e.g., teacher, mother, friend, boyfriend, girlfriend).
b1 b4     
    
b2 b5     
    
b3 b6     
    
For the two most important of these interactions, use the table below to give a brief description of the interaction. The first row contains an example.
Who was the
person?
Describe the interaction
Posivity
rating
*
Importance
rating**
Why was it important?
What impact did it have on you?
   
  
 
  *Positivity Scale    1(extremely negative)      2(moderately negative)   3(Neutral)   4(Moderately positive)   5(Extremely positive)
 **Importance Scale 1(not at all important)     2                                   3(Moderately Important)        4        5(Extremely important)
Were there any other significant events (not social interactions) that made you think negatively about your own abilities and/or potential? Examples may be hearing someone make a comment in class, seeing something on television, reading something, receiving a test grade, learning important news about one of your friends or family members. Use the table below to list and describe these these events.
Describe the Event
Positivity
Importance
Why was it important?
What impact did it have on you?
  *Positivity Scale    1(extremely negative)      2(moderately negative)   3(Neutral)   4(Moderately positive)   5(Extremely positive)
 **Importance Scale 1(not at all important)     2                                   3(Moderately Important)        4        5(Extremely important)

Did any of these interactions or events make you feel as if some thing might be impossible for you to do that you had considered possible before?   Yes   No  
Please explain:

 


Created by H. Lips & W. Andrew.
Copyright 2000 [Center for Gender Studies]. All rights reserved.
Current Date: February 20, 2001