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    Survey Questionnaire

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    Robelyn Abing
    The document contains a demographic data form and mental health questionnaire for research respondents of Jose Rizal Memorial State University's College of Education. The demographic data form collects information such as name, age, gender, civil status, course/program, year of study, family monthly income, and living condition. The mental health questionnaire contains 20 statements about various feelings and asks respondents to rate themselves on a 4-point scale to help determine mental health issues during the pandemic.

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    © All Rights Reserved
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    Survey Questionnaire

    Uploaded by

    Robelyn Abing
    21 views2 pages
    The document contains a demographic data form and mental health questionnaire for research respondents of Jose Rizal Memorial State University's College of Education. The demographic data form collects information such as name, age, gender, civil status, course/program, year of study, family monthly income, and living condition. The mental health questionnaire contains 20 statements about various feelings and asks respondents to rate themselves on a 4-point scale to help determine mental health issues during the pandemic.

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    Survey-Questionnaire

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    The document contains a demographic data form and mental health questionnaire for research respondents of Jose Rizal Memorial State University's College of Education. The demographic data form collects information such as name, age, gender, civil status, course/program, year of study, family monthly income, and living condition. The mental health questionnaire contains 20 statements about various feelings and asks respondents to rate themselves on a 4-point scale to help determine mental health issues during the pandemic.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    21 views2 pages

    Survey Questionnaire

    Uploaded by

    Robelyn Abing
    The document contains a demographic data form and mental health questionnaire for research respondents of Jose Rizal Memorial State University's College of Education. The demographic data form collects information such as name, age, gender, civil status, course/program, year of study, family monthly income, and living condition. The mental health questionnaire contains 20 statements about various feelings and asks respondents to rate themselves on a 4-point scale to help determine mental health issues during the pandemic.

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    Republic of the Philippines

    JOSE RIZAL MEMORIAL STATE UNIVERSITY


    The Premier University in the Province of Zamboanga del Norte
    KATIPUNAN CAMPUS
    Katipunan, Zamboanga del Norte

    COLLEGE OF EDUCATION
    Demographic Data of the Research Respondents

    Name:____________________________Age:______________________

    Gender:___________________________Civil Status:________________

    Course/Program: ____________________Year of Study:_____________

    Family Monthly Income:( Please check on the space provided)

    8,000-10,000 [ ]

    6,000-7,999 [ ]

    4,000-5,999 [ ]

    2,000-3,999 [ ]

    1,000- below [ ]

    Living Condition: (Put a check on the space provided that corresponds to your answer)

    Live Alone [ ]

    Live with parents [ ]

    Live with one of parents [ ]

    Live with my own family [ ]

    Live with friends/roommates [ ]


    Republic of the Philippines

    JOSE RIZAL MEMORIAL STATE UNIVERSITY


    The Premier University in the Province of Zamboanga del Norte
    KATIPUNAN CAMPUS
    Katipunan, Zamboanga del Norte

    COLLEGE OF EDUCATION
    Name (Optional):_____________________ Age:___________________
    Program/Year Level:__________________ Gender:_________________

    Direction: Please check (/) and rate yourself honestly. Your honesty in answering this questionnaire will
    help us a lot in determining the Mental Health issues during pandemic.
    20. I have felt calm and relax.
    Yes, Yes, No No not at
    21. .I have felt active and vigorous. definitely sometimes not much all
    22. My daily life has been filled with (4) (3) (2) (1)
    things
    1. I feelthat interest
    anxious me. I go out on the
    when
    house on my own.
    23. .I woke up feeling fresh and
    2. I get palpitations, or sensations of
    rested .
    “butterflies” in my stomach or chest.
    3. I feel scared or frightened.
    24. I feel hopeful about the future.
    4. I am more irritable than usual.

    5. I get very frightened or have panic


    feelings for apparently no reason at all.
    6. I am restless and can’t keep still.

    7. Worrying thoughts constantly go


    through my mind.
    8. I wake up early and then sleep badly
    for the rest of the night.
    9. I feel miserable and sad.
    10. I have a good appetite.
    11. I feel life is not worth living.
    12. I still enjoy the things I used to do.
    13. I feel as if I have slowed down
    14. I have lost interest in things.

    15. I experienced mood swing.

    16. Feel fear.


    17. Experience tiredness
    18. Often feel confused.
    19. I am sad.

    20. I have felt cheerful and in good


    spirit.

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