Appendix

CANOSSA ACADEMY
SAN CARLOS, LIPA CITY 4217
Tel. Fax (043) 75611819, Tel. (043) 7561329
PAASCU Accredited

Good day! We, grade 12 students from Canossa Academy, would like to conduct a
survey regarding the Effectiveness of the Implementation of the Code of Discipline in the
Junior High School Department at Canossa Academy, Lipa City. This survey is executed as the
results will be used in accomplishing our research paper for the year 2018-2019. We appreciate
your utmost participation and generosity. This will only take about 15 minutes of your time and
we assure you that all answers provided will be kept strictly confidential.

Part 1

Questions: Yes No Questions: Yes No

Do you come to school late? Do you have unexcused or

habitual absences?
Do you wear improper uniform or Do you skip or cut classes?
outfit during school days?
Do you put other unnecessary Do you litter?
décor on your IDs?
Do you wear improper PE uniform Do you loiter around during
and shoes during school days? class hours?
Do you wear excessive earrings, Do you have distractive
long fingernails and manicure? behavior? (distractive behavior is
when students distract their peers from
doing academic matters. Usually,
distractive behavior involves being noisy,
and sleeping in class.)
Do you wear make up? Do you lie deliberately?
Do you wear colored contact lens? Do you deceit authority?
(Deception to authority means telling
someone of authority that you will do the
orders that he/she has given to you but
eventually you just trick that person in
making him/her believe in what you said.)
Do you not submit your excuse Do you use profane,
letter for absences or tardiness obscene, indecent or
upon his return the following day? offensive language?
Do you eat along the corridors? Do you improperly use the
comfort room or other
school facilities?
Do you not submit your report Do you spit in public
cards, acknowledgement receipt, places?
student handbook reply slip, parent
agreement contracts, return slips,
violation reports and other official
correspondence on or before the
deadline?
Do you leave the classroom Do you go to the mall, hang
without class pass or misuse the out in public places or
class pass to go to the canteen or watch movies in your
elsewhere? uniform?
Do you violate the rules of the Do you act dishonestly?
library, laboratory, home (cheat, provide answers for other students,
use codigo or allowing others to cheat in
economics or AVR/viewing room? all form of tests, projects or other school
requirements)
Do you play any form of ball Do you unnecessarily talk,
games except during scheduled PE giggle, shout, howl, chew
time? gum, tease, provoke or any
other unauthorized
interruptions of proceedings
in the classroom, along the
corridors, auditorium,
chapel lecture hall or during
flag ceremony, prayer
meetings or any official
activity?
Do you watch pornographic Do you bring cell phones
materials in the internet, laptops, and other electronic devices
mobile phones inside school (cameras, tablets, laptops, etc) without
premises? written permission from the
parents authorized by the
Prefect of Discipline?

N= Never S= Seldom So= Sometimes O= Often A= Always

Part 2

N S So O A
The code of discipline is yearly discussed to the students by the
1 2 3 4 5
administrators
I am aware of the consequences when I break a school rule /
1 2 3 4 5
regulation
I always receive an infraction when I commit a violation 1 2 3 4 5
I stopped committing violations after receiving my infraction 1 2 3 4 5
I have never been exempted from receiving an infraction without
1 2 3 4 5
a valid reason

N= Never S= Seldom So= Sometimes O= Often A= Always

Part 2.1 (Level I)

N S So O A
 I received conference with my adviser after my first violation 1 2 3 4 5
I received conference with my adviser and parents after my
1 2 3 4 5
second violation
I received conference with my adviser, prefect of discipline and
with my parents, community work for 3 hours after my third 1 2 3 4 5
violation
I received conference with my adviser, prefect of discipline and
with my parents, 1 day ordinary suspension and issuance of 1 2 3 4 5
behavioural contract after my habitual violation

N= Never S= Seldom So= Sometimes O= Often A= Always

Part 2.2 (Level II)

N S So O A
I received conference with my adviser, prefect of discipline and
parents, community work for 3 hours, zero in test, activities,
1 2 3 4 5
projects, etc and my gadget was confiscated after my first
violation
I received conference with my adviser, prefect of discipline and
parents, 1 day ordinary suspension, zero in test, activities,
1 2 3 4 5
projects, etc and my gadget was confiscated after my second
violation
I received conference with my adviser, prefect of discipline and
parents, 1 day ordinary suspension, zero in test, activities,
1 2 3 4 5
projects, etc and my gadget was confiscated after my third
violation

SD= Strongly Disagree D= Disagree N= Neutral

A= Agree SA= Strongly Agree

Part 3

SD D N A SA
I am more open to reality, truth and growth of oneself with the
1 2 3 4 5
help of the code of discipline
I am a genuine human being and I take upon myself a personal
responsibility to recognize, encourage myself and others in each
1 2 3 4 5
one’s potential and unique giftedness with the help of the code of
discipline
I am more appreciative with my Filipino roots with the help of
1 2 3 4 5
the code of discipline
I am able to integrate within myself, as well as others, to accept
cultural differences and racial and ethnic wrath with the help of 1 2 3 4 5
the code of discipline
I have the desire and willingness to share talent and time in
1 2 3 4 5
building school/faith communities with the help of the code of
discipline
I am trusting, understanding, zealous, persevering, patient and
1 2 3 4 5
cooperative with the help of the code of discipline
I am an information seeker and sharer who has learned to listen,
communicate and is capable of assuming different positions and 1 2 3 4 5
roles in any group with the help of the code of discipline
I can coordinate group interactions and activities, accept and
integrate ideas and suggestions of others with the help of the code 1 2 3 4 5
of discipline
I can draw together divergent viewpoints and activities for the
1 2 3 4 5
common good with the help of the code of discipline
I work toward the well – being and equality of persons with the
1 2 3 4 5
help of the code of discipline
I engage myself in programs and projects which promote social
1 2 3 4 5
justice and peace with the help of the code of discipline
I am able to respond peacefully even when met by violence with
1 2 3 4 5
the help of the code of discipline
I treat the earth non-violently, conserve resources and respect the
1 2 3 4 5
delicate ecological balance with the help of the code of discipline
I am honest, sincere and transparent with my words and actions
1 2 3 4 5
with the help of the code of discipline
I am also self-disciplined and I know how to delay gratification
1 2 3 4 5
with the help of the code of discipline
I can weigh facts objectively, suspend judgement until further
evidence and can wait calmly for life’s gradual unfolding 1 2 3 4 5
revelation with the help of the code of discipline
I am a person with vision who can value, take a stand and act and
1 2 3 4 5
live by what I believe with the help of code of discipline
I am a concerned citizen who unifies past situations, present
experiences and future thrusts in building life-giving and love- 1 2 3 4 5
nurturing environments with the help of the code of discipline
I discover issues beyond the limits of self-concern and reach out
1 2 3 4 5
freely to others with the help of the code of discipline
I promote social justice, peace and the good of the poor, the
1 2 3 4 5
disadvantages with the help of the code of discipline
I develop within myself the necessary life-learning tools for
communication, problem solving, decision making and creativity 1 2 3 4 5
with the help of the code of discipline.
I demonstrate confidence in thinking, expressing and working as
well as a mastery in my subject areas with the help of the code of 1 2 3 4 5
discipline
I am reflective and able to relate ordinary and significant events
and experiences to my life, family, parish and acts based on 1 2 3 4 5
Christian principles with the help of the code of discipline
I participate willingly and actively in liturgical practices with the
1 2 3 4 5
help of the code of discipline
I am equipped with knowledge of Christ and am a sharer of
1 2 3 4 5
God’s love with the help of the code of discipline
 Part 4

Do you think the Code of Discipline is effective?

(in bullet form)

If YES, state here the possible reasons why: If NO, state here the possible reasons why:

____________________________________ ___________________________________
____________________________________ ___________________________________
____________________________________ ___________________________________

Why do you follow the code of discipline? Why do you not follow the code of discipline?

Check as many as needed:

o My parents will get mad at me if I do o It does not let me express my

not individuality
o It is necessary o It is hard for me to follow
o It teaches me how to respect higher o I do not care
authority o It is irrelevant
o It teaches me values and morals o The infractions are not always handed
o It helps me to develop my own out
discipline o I can get away easily
o It is the right thing to do o I do not believe it is useful
o It provides a stable school climate o The discipline officers are not strict
o I’m scared of getting punished o I do not consider respecting authority
o Others, please specify: o I am not scared of the punishment
_______________________ o It seems to be just a threat
_______________________ o It does not teach me anything valuable
_______________________ o Others, please specify:
_______________________
_______________________
_______________________