Personal Barriers

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Name* This field is required.
First Name
Last Name
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Email* This field is required.
example@example.com
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Question 1: Review the internal beliefs and tendencies many people experience

Fixed Mindset: belief that one's [intellectual, physical, etc.] abilities are limited and unchangeable

Perfectionism: striving for flawlessness or excessively high standards; fixating on imperfections, trying to control situations, working hard, and/or being critical of one's self or others

Underrepresentation: feeling like the "only" or "other" due to demographic, socio-economic and background characteristics unique to an individual (education, race/ethnicity, gender identity, ability, specialty choices, faith/religion, etc.)

Performance-based Self-Esteem: one's self-worth is contingent upon his/her sense of accomplishment and perceived level of performance

Imposter Syndrome: A belief of being less competent than others perceive, associated with chronic feelings of self-doubt and fear of being discovered as a fraud. ‘Am I good enough? What if someone figures me out? Why did she/he/they hire me, marry me, admit me to this program
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In the last 12 months, which tendencies have you experienced most often? Drag to rank each from 1 (most frequently) to 5 (least frequently)* This field is required.
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Question 2: Review the environmental conditions that many people experience

Psychologically Unsafe Environments: settings in which one does not feel safe taking risks, speaking up, engaging with uncomfortable learning processes or revealing their authentic selves

Institutional Expectations: the perceived standards expressed, either implicitly or explicitly, to workers/students/members about their expected performance within the institution

The Rigors of Life: the challenging nature of life (learning, work/career, relationships/marriage, etc.)
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In the last 12 months, how often have these environmental conditions led to feelings of discomfort or concern? Rank from 1 (most frequently) to 3 (least frequently)* This field is required.
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Question 3: Review the thoughts and tendencies that many people experience

Comparisons to Others: self-evaluating based upon contrasting one's own life with the life of others

Fear of Judgment: concerns over being judged harshly by others, often coupled with efforts to maintain others' impressions and perceptions

Shifting Identity: changes in self-image and sources of self-worth that occur after entering and assimilating to a new environment, situation, or relationship

Impaired Belonging: feeling isolated or a sense of not belonging in the learning environment
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In the last 12 months, which thoughts have you experienced most often? Rank from 1 (most frequently) to 4 (least frequently)* This field is required.
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Overall, in the last 12 months, which of the 12 tendencies have you experienced most frequently ? Select the top four.* This field is required.
Fixed Mindset
Perfectionism
Underrepresentation
Performance-based Self-Esteem
Imposter Syndrome
Psychologically Unsafe Environments
Institutional Expectations
The Rigours of Life
Comparisons to Others
Fear of Judgment
Shifting Identity
Impaired Belonging
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Age Range* This field is required.
Please Select
Please Select
18-24
25-34
35-44
45-54
55-64
65-74
75 or older
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Gender Identity* This field is required.
Please Select
Please Select
Male
Female
Transgender
Non-binary/non-conforming
Prefer not to respond
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Race/Ethnicity* This field is required.Select all that apply
American Indian or Alaska Native
Asian
Black or African American
Hispanic, Latino, or Spanish Origin
Native Hawaiian or Other Pacific Islander
White
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Education* This field is required.Select highest level of education completed
Please Select
Please Select
8th grade or less
Some high school, no diploma
High school diploma/GED
Some college credit, no degree
Trade/technical/vocational training
Associate degree
Bachelor’s degree
Master’s degree
Professional degree
Doctorate degree
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Marital Status* This field is required.Select highest level of education completed
Please Select
Please Select
Single, never married
Married or domestic partnership
Widowed
Divorced
Separated
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Employment Status* This field is required.Select highest level of education completed
Please Select
Please Select
Employed for wages
Self-employed
Unemployed
A homemaker
A student
Military
Retired
Unable to work
Should be Empty: