APPENDIX

SURVEY QUESTIONNAIRE
PART I PROFILE OF THE RESPONDENT
Direction : Please put a check mark (/) on the appropriate box corresponding to
your answer for each item below or give the required information by filling out the
blanks.
1. Name (Optional ) : _____________________________________________
2. Age :
( ) 15 44 years
( ) 45 - 60 years
( ) above 60 years
3. Highest Level of Education:
( ) Elementary Level ( ) College Level
( ) Elementary Graduate ( ) College Graduate
( ) High School Level ( ) Postgraduate
( ) High school Graduate
Part II-A. Knowledge about Airborne Transmitted Disease: cause and nature,
mode of transmission and prevention of infection and/or transmission.
Please read each statement carefully and rate each one in terms of your
agreement (Yes) or disagreement (No) by putting a check mark (/) on the box
corresponding to your answer.
Airborne Transmitted Diseases refer to the following:
(a) Tuberculosis, pulmonary 2 weeks
(b) Influenza. 1-4 days
(c) Pneumonia.. 7-10 days
(d) Chicken pox with pulmonary
involvement 14-15 days
2

Period of transmission (incubation) common |SSx, effectivity period of
treatment

Statements about Airborne Transmitted Diseases
Agreement or
Disagreement
YES NO
1. Airborne transmitted disease (ATD) can kill.
2. A person who is having cough is immediately a
suspect for ATD

3. ATD causative organisms are spread through the air
whenever a person with the disease coughs and
sneezes.

4. A person sick with ATD must cover his mouth and
nose with an appropriate mask to prevent expulsion of
the germs into the air when he sneezes or coughs.

5. ATD is not preventable nor curable.
6. A person with productive cough for a week or two
two weeks is sick with ATD.

7. Smoking cigarettes is not among the predisposing
factors for ATD.

8. To protect oneself from getting ATD one must
practice or adhere to a healthy lifestyle.

9. ATD is an infection of the respiratory system.
10. ATD infected person may also have any or a
combination of the following symptoms: chest pains,
body malaise (weakness) and weight loss in addition
to productive cough and low grade fever of 2 weeks
duration. SSX?

11. A person suspected to be sick with ATD must
immediately consult or seek the help of a health
worker (nurse, doctor).

12. A person who was given proper treatment for at
least two weeks will still spread the TB germs or
bacilli.

3

13. A child diagnosed to have weak lungs (primary
complex) has tuberculosis.

14. Drinking liquor and other alcoholic drinks
increases the likelihood of getting infected with ATD.

15. A person who has fully recovered from ATD is
protected against the disease even if there is constant
exposure to a person with ATD.

16. A gap of at least one foot away from another
person is a safe distance when isolating an
infectiousATD.


B. Attitude including perceptions of social stigma towards Tuberculosis:


Statements about ATD
Agreement or
Disagreement
YES NO

1. A person sick with ATD cannot work or be
among a group of people even when proper
treatment has been started.

2. ATD patient must not be seen in public places.
3. It is better not to receive anti-ATD treatment than
receive improper treatment.

4. It is better to be sick with cancer than ATD
5. A person diagnosed to have ATD may be treated
as an out-patient and allowed to go home.

6. The fact that one has ATD must be kept strictly
confidential.

7. A person diagnosed to have ATD must be
confined in a hospital until he fully recovers from
the illness.

8. A fully recovered ATD patient can do things a
normal and healthy person does.

4


C. Practices Perceived to be Effective Against TB disease Spread and Infection:

Statements about Tuberculosis
Agreement or
Disagreement
YES NO
1. One can stay in poorly ventilated rooms even if
occupied by An ATD suspect or infected person.

2. ATD suspect must immediately submit himself
or herself for diagnostic examination.

3. It is okay for adults diagnosed to have ATD to
stay close to his/her children.

4. One must keep the DOH cough etiquette a habit.
5. One must avoid spitting whether in public or
private places.

6. It is okay to discontinue ATD treatment before
the requisite 6 month or 8-month period.

7. It is not necessary for ATD infected person to
cover his mouth and nose with an appropriate
mask.

8. Proper body nourishment, enough periods of rest
and sleep keep a person less susceptible to
ATDinfection.


Thank you for your time and cooperation.




5

TB as a disease (Question number 1,5-.9-,13)
Signs and symptoms & Risk factors (Question number 2-,6-,10,14)
Disease Transmission (Question number 3,7-,11,15-)
Preventive and health promotive practices (Question number 4,8,12-,16-)
Attitude (Question number 1-,3,5,7-)
Social stigma (Question number 2-,4-,6-,8)
Practices Perceived to be Effective Against TB disease Spread: (Question
number 1-,2,3-,4,5,6-,7-,8)