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Questionnaire: TO THE XXXXXXXXXX: This Questionnaire Is NOT A Test But Simply A Survey On The Effects of

This document appears to be a questionnaire about the effects of some topic (referred to as "xxxxxxxxxx" throughout) on another topic (also referred to as "xxxxxxxxxx"). The questionnaire collects information on the respondent's profile, ratings of the level of effects of "xxxxxxxxxx" on "xxxxxxxxxx", ratings of the respondent's awareness of these effects, and ratings of proposed ways to deal with these effects. The respondent is asked to provide ratings on a 5-point scale for various statements in each section.

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sheree gaye orenya
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2K views

Questionnaire: TO THE XXXXXXXXXX: This Questionnaire Is NOT A Test But Simply A Survey On The Effects of

This document appears to be a questionnaire about the effects of some topic (referred to as "xxxxxxxxxx" throughout) on another topic (also referred to as "xxxxxxxxxx"). The questionnaire collects information on the respondent's profile, ratings of the level of effects of "xxxxxxxxxx" on "xxxxxxxxxx", ratings of the respondent's awareness of these effects, and ratings of proposed ways to deal with these effects. The respondent is asked to provide ratings on a 5-point scale for various statements in each section.

Uploaded by

sheree gaye orenya
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Name (Optional): ___________________________ Date: ____________________________


Address: __________________________________

QUESTIONNAIRE
TO THE XXXXXXXXXX: This questionnaire is NOT a test but simply a survey on the effects of
xxxxxxxxxx on xxxxxxxxxx. Please follow the direction for each part of the questionnaire carefully. Rest
assured that your responses will be treated with utmost confidentiality. Thank you very much.

I. PROFILE OF THE XXXXXXXXXX


Direction: Supply the needed data.
A. AGE (on last birthday): __________ B. SEX: __________
C. XXXXXXXXXX: __________

II. EFFECTS OF XXXXXXXXXX ON THE XXXXXXXXXX


Direction: Put a check (✔) according to the following codes:
Code Verbal interpretation Meaning
(Description)
5 Extreme effect Total impact
4 High effect Great impact
3 Moderate effect Has some impact
2 Low effect Little impact
1 No effect No impact

EFFECTS OF XXXXXXXXXX ON THE XXXXXXXXXX 5 4 3 2 1


1. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
2. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
3. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
4. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
5. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
6. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
7. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
8. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
9. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
10. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
Others (Please specify.) _________________________________________________________________

III. LEVEL OF AWARENESS OF THE XXXXXXXXXXX ABOUT THE EFFECTS


OF XXXXXXXXXX ON XXXXXXXXXX
Direction: Put a check (✔) according to the following codes:
Code Verbal interpretation Meaning
(Description)
5 Extremely aware Has total awareness
4 Very aware Has great awareness
3 Moderately aware Has some awareness
2 Slightly aware Has little awareness
1 Not aware at all No awareness at all
2

LEVEL OF AWARENESS OF THE XXXXXXXXXX 5 4 3 2 1


ABOUT THE EFFECTS OF XXXXXXXXXX
ON XXXXXXXXXX
To what extent are you aware that…
1. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
2. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
3. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
4. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
5. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
6. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
7. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
8. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
9. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
10. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx?
Others (Please specify.) _________________________________________________________________

IV. WAYS PROPOSED BY THE XXXXXXXXXX TO DEAL WITH THE EFFECTS


OF XXXXXXXXXX
Direction: Put a check (✔) according to the following codes:
Code Verbal interpretation Meaning
(Description)
5 Completely agree In total agreement
4 Mostly agree Agree for the most part
3 Moderately agree Agree for some part
2 Slightly agree Agree for the least part
1 Do not agree at all In total disagreement
WAYS PROPOSED BY THE XXXXXXXXXX TO DEAL 5 4 3 2 1
WITH THE EFFECTS OF XXXXXXXXXX
1. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
2. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
3. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
4. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
5. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
6. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
7. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
8. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
9. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
10. Xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx.
Others (Please specify.) ________________________________________________________________

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