Laguna College

Department of Nursing

Survey Questionnaire

A Study about the Difficulties and Coping Mechanisms of High School Students Caused by Maternal Absence Name (optional): _________________________________ Age: ______________ Sex: __________

Year and Section: _________________ Mother: ___ OFW ___ Deceased ___Separated Presently, Im living with my ____Father ____Grandparents ____Brother/Sister ____Aunt/Uncle ____if others, please specify: ___________ Monthly Family Income: _____ 70,000 and above _____ 50,000 69,999 _____ 20,000 49,999 _____ 1,000 19,999

Part I. Difficulties regarding maternal absence Directions: Please put a check mark ( answer. A. EMOTIONAL ) inside the box that corresponds to your

In response to the maternal absence, 1. I need a lot of time and space to work out my thoughts and feelings. 2. I dont think it is good for me to be left by my mother. 3. I believe that Im on the right age to be independent. I dont think I really need the guidance of my mother. 4. I got mad with my mother when she left me. 5. I dont think my mother really cares for me because she left me. 6. I dont understand why my mother left me. 7. I dont consider my guardian every time Im making a certain decision. 8. I dont think that my family/guardian cares for me. 9. I felt alone when my mother left me. 10. My anger and hurt feelings regarding my mother turn to tears.

Strongly Disagree (4)

Disagree (3)

Undecided (0)

Agree (2)

Strongly Agree (1)

B. HEALTH

In response to the maternal absence, 1. I eat junk foods and soft drinks since my mother left me. 2. I include fast food in my diet (three or more times per week). 3. I have dark circles under MY eyes. 4. I run out of energy during the day. 5. I have recurrent nightmares or distressing dreams since my mother left. 6. I feel less interested in activities or hobbies that I once enjoyed. 7. I had difficulty falling or staying asleep. 8. I had difficulty in concentrating. 9. I feel my bodys resistance got weak since my mother left me. 10. I lose my appetite since my mother let me.

Always

Every other Day

Once a Week

Once a Month

Never

C. SOCIAL In response to the maternal absence, Strongly Disagree Undecided Agree Disagree Strongly Agree

1. I dont believe that Im practicing my social skills as I interact with real world. 2. I cant always perform my responsibilities such as doing school works.

3. I felt being rejected by my friends/classmates because I dont have my mother beside me. 4. I dont like involving in a club, sports, community activity or youth group that includes adolescents like me. 5. I dont ask permission from my guardian every time I go out. 6. I dont feel that I get freedom and independence even though I dont have a mother beside me. 7. Id rather tell my secrets to my peers/friends rather than my guardian. 8. I tell a lie to my guardian just to have time with my peers/opposite sex. 9. What I am right now is the influence of my friends/peers. 10. I dont communicate everyday with my family, especially my mother. (if OFW/Separated)

Part II. Coping mechanism due to maternal absence. In response to the maternal absence, 1. I felt hopeless ever since my mother left me. 2. I cry easily ever since my mother left me. 3. I felt guilty why my mother left me. 4. I find myself over-eating ever since my mother left me. 5. I withdrew from my friends when my mother left me. 6. I have difficulty in decision Strongly Disagree Undecided Disagree Agree Strongly Agree

making. 7. I spent much time on my room alone when my mother left me. 8. I often felt fatigued even when I got enough rest. 9. I quit activities I used to enjoy when my mother left me. 10. I find hard time focusing on homework or reading when my mother left me.

Criteria: For Difficulty 30 40 = with extreme difficulty 20 29 = with difficulty 10 19 = with minimal difficulty 09 = without any difficulty

For Coping Mechanism 30 40 = Cannot Cope 20 29 = With poor coping mechanism 10 19 = With good coping mechanism 09 = With effective coping mechanism