General Instructions: Answer the following questions HONESTLY and DO NOT SKIP a

part of this questionnaire for it will render your answers to the

previous chapters INVALID.
For validity purposes, we encourage the participants to write their
FULL NAME and OTHER PERTINENT DETAILS that this questionnaire
seeks.

PART I: BASIC INFORMATION

Instructions: Write each letter of your name on the boxes below. If your name consists
of two words, skip a box for the space and continue to write the letters of
your second name in the succeeding box. If your name so includes a suffix,
(Jr., II, III, etc.) skip another box for the space and write it after your
first/given name. If your name has , write it as it is on the box.

First/Given Name:

Middle Name:

Last Name:

School/
University:___________________________________________________________________
_____________________________
Course/Major/Degree of
Concentration:______________________________________________________________
__________
Assigned Working
Department:________________________________________________________________
__________________
Nature of work:_____________________________________ Number of hours per
shift:__________________________
Number of months/years you have been working:__________________________________
Age:____________ Sex:____________________ Date of
Birth:_______________________(MM/DD/YY)
Nationality:_____________________________________ Place of
Birth:_________________________________________
Temporary
residence:_____________________________________________________________________________
_______________
Provincial
address:_______________________________________________________________________________
_________________
Contact Number:___________________________________ E-mail
Address:________________________________________

In your status and if you are currently in a relationship with someone,

(boyfriend/girlfriend/live-in partner) please indicate the in a relationship with my
boyfriend/girlfriend/live-in partner. Or if none, you can write Single. If Married, indicate
how many years youve been married with your spouse. If Widowed, indicate how many
years youve been single since your spouses passing. This question is important and is
interrelated to the following part or chapter. Please answer accordingly.

Status:_________________________________________________________________

How many are you in the family?_____________________

How many siblings do you have in the family?_____________________ Are you an
only-child?____________
Are you the eldest?____________ Are you the youngest?______________ You are in
chronologically, what order among your siblings? I am ____________________________(first,
second, third, etc).
Is your father currently working/employed?_____________
What does he do for a living?
__________________________________________________________________________________
Is your mother currently working/employed?___________
What does she do for a living?
_________________________________________________________________________________
Are you self-employed?__________________________ Do you solely support your studies as
a student assistant or scholar?__________________________ Is your family income enough
to support your family?__________________

PART II: YOUR HEALTH

Instructions: Answer the questions APPROPRIATELY and HONESTLY. Any confidential

information divulged in this questionnaire will not appear anywhere in the
study conducted. This is for statistical purposes. However, we do
encourage you to answer every question even if it will not appear on the
data for validity purposes. If the question is not applicable to you, write
N/A.

Do you have heart problems?_____________________ If so, what is it?

__________________________________
Is it life threatening?__________ Is it curable?___________ Are you currently taking
medication?______________
Do you have ANY health problems?_______________ If so, what is it?
__________________________________
Is it life threatening?__________ Is it communicable/transferrable to another?
____________
Is it curable?___________ Are you currently taking medication?______________
How many years have you endured this health problem?__________
Did you inherit this disease?_________ Is it from your mothers or fathers side?
________________________
--------------------------------------------------------------------------------------------------------------------------
---------Instruction: Answer the questions HONESTLY. Check ( ) the appropriate box for
your answer.

NEVER ONCE OCCASIONA FREQUENTL ALWAYS

LY Y
I drink 8 glasses
of water
everyday.
I drink alcoholic
beverages.
I smoke.
I sleep 8 hours a
day.
I drink food
supplements.
I eat meals 3
times a day.
I exercise.
I do noontime
naps or rest.
I do stress-
relieving
activities.
I get stressed
easily.
I get mood
swings easily.
I get suicidal
thoughts.
I attempted to
commit suicide.

How many hours do you usually sleep?___________ What time do you usually go to
sleep?___________

Do you get suicidal thoughts from time to time?_____________ What caused you to think
this?______________
________________________________________________________________________________________
______________________
Did you already attempt to commit suicide?_________________ What caused you to do
this?________________
________________________________________________________________________________________
_____________________
Did you share this with your family?_________ Why/why not?
_____________________________________________
________________________________________________________________________________________
______________________
Did you share this with your firends?________ Why/why not?
_____________________________________________
________________________________________________________________________________________
______________________
What causes you stress or uneasiness?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
____________________________________________
What stress-relieving activities do you usually do?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________
What are your hobbies that you usually do on your weekends?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________
What sports or physical activities do you usually get into?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
___________________________________________________________________________________
Does it help you relax?________ Does it make you happy?________
With whom do you usually enjoy your hobbies?
_______________________________________________________________
Do you have a known phobia?___________________ What is it?
____________________________________________________(fear of heights, water, close space,
etc.)
How do you usually overcome your fear?

________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________
What is your greatest fear?
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________
How would you overcome this fear if it happens?
_______________________________________________________________
________________________________________________________________________________________
_______________________________
________________________________________________________________________________________
_______________________________

PART III: YOUR RELATIONSHIPS

Instructions: Answer the questions APPROPRIATELY and HONESTLY. Any confidential

information divulged in this questionnaire will not appear anywhere in the
study conducted. This is for statistical purposes. However, we do
encourage you to answer every question even if it will not appear on the
data for validity purposes. If the question is not applicable to you, write
N/A.
FAMILY

Are you a legitimate son/daughter?___________________________________ Is your family a

legitimate or illegitimate one?__________________________ Do you have step sisters or
brothers?______________________________
How many?_______________ Are you close with them?
___________________________________________________________
Are you originally from Cebu?___________ If not, are you here because of your studies?
______________________
Are you currently living with your parents?_____ How many years have you been living
with them?______
Are you living with your relatives at the moment?________ Do they have children as
well?__________________
Do they go to the same school as you?_________ Are you close with these relatives?
__________________________
Do you have close ties with your parents?________ To whom do you usually confide your
problems, is it to your father or mother?________________________ What kinds of problem
do you usually share with your father or mother?
________________________________________________________________________________________
__________
________________________________________________________________________________________
______________________________
Do your parents or either of them give you advice in regards to your problems?
___________ Do you have fights with your parents? _________ What is usually the cause of
your arguments?___________________________
________________________________________________________________________________________
________________________________________________________________________________________
Do you make up with your parents after your fight?
___________________________________________________________
Do you have close ties with your siblings?________ To whom do you usually confide your
problems among your siblings?______________________________ What kinds of problem do
you usually share with your sibling confidant?
________________________________________________________________________________________
__________
________________________________________________________________________________________
______________________________
Does your sibling confidant give you advice in regards to your problems?___________ Do
you have fights with your siblings? _________ What is usually the cause of your fights?
________________________________________
________________________________________________________________________________________
Do you make up with your siblings after your fight?
___________________________________________________________
________________________________________________________________________________________
Are you close with your other blood relatives?________________ Do you often visit their
place?_______________
Do you have close bonds with your cousins?_____________________ Did you experience a
fight with your cousins?____________ How did your relatives, especially your uncles and
aunts react to that?________________
________________________________________________________________________________________
_______________________________
________________________________________________________________________________________
_______________________________
Are you an introvert when it come to your family?________________ If not, then are you
interactive or close with them?________________

FRIENDS

Do you have friends?__________ How many friends do you have?_____________ Are you
of the same age with them?_________ For how many years or months are you friends
with them? ________________________ Do you consider them as your true friends?
_____________ Are they in the same school as you?_________________ Are they in the
same college department?________________________________ Do you often go out
together?__________ To whom do you usually confide your problems among your friends
____________________________________________________________ Do you consider him/her
your bestfriend?__________ What problems do you usually share to this friend?
________________________________________________________________________________________
_______________________________
Does he/she give useful advice to you?__________________ Do you often follow those
advices he/she gave?____________________ Was it effective ?____________ Did the advices
solve your problem?__________________
________________________________________________________________________________________
_______________________________
Did you experience being backstabbed or betrayed by your friends?
_________________________________________ For what reason?
___________________________________________________________________________________ Did
you make up with your friend/s who betrayed you?____________ Were you able to
forgive them/him/her completely for what they/he/she did?
_________________________________________________________ Would you consider your
friends important to you?
________________________________________________________________________
In what way?
________________________________________________________________________________________
_______________
________________________________________________________________________________________
_______________________________
Do you live with some of your friends (same boarding house, etc)?________ Do you
always go together when going home/to your temporary residence?_________ Do you
usually make your school projects with your friends?________ How many school projects
do you usually have everyday?____________________________
Do your friends give you a helping hand everytime you ask for their help?_____ Are they
kind to you?____
Are your friends mostly boys?__________________________ Are your friends mostly girls?
_______________________
Are you an introvert when it comes to your friends?______________ If not, then are you
interactive or close with them?_________________________

PARTNER

Do you like someone (crush type) from the opposite sex?___________ Are you of the
same age?_____________
Is that person younger or older than you?_____________________________ By how many
years?_________________________________________ Is he/she studying?
_____________________________ Is he/she from the same university?_____________ Is
he/she studying in the same college department? __________ Is he/she in the same year
level with you?_______________ Are you currently in a relationship with that person?
_________ By how many years or months?______________________________________ Are you
friends with that person?___________ Are you close with that person?
_____________________________ Do you usually converse with that person?
_______________________________ What do you usually talk about?__________________
________________________________________________________________________________________
______________________________
What do you like about him/her?
________________________________________________________________________________
________________________________________________________________________________________
_______________________________
Did you tell him/her that you like him/her?________________ Are you going to tell
him/her?_________________
Why or why not?
________________________________________________________________________________________
___________
Would you consider him/ her important to you?_____________ In what way?
__________________________________
________________________________________________________________________________________
_______________________________
Would you consider pursuing him/her?_________________ Why or why not?
____________________________________
________________________________________________________________________________________
_______________________________
Are you widowed?__________ How many years has it been from your spouses passing?
____________________
Would you consider remarrying?________ Why or why not?
____________________________________________________
________________________________________________________________________________________
_______________________________
Are you currently in a relationship with someone?___________ For how many years or
months are you together with him/her? (Not necessarily living together)________________
Is your partner younger or older than you?______________________ By how many years?
________________________________ Do you get into deep conversations with your
partner?_____________ What do you usually talk about?______________________________
________________________________________________________________________________________
_______________________________
Do you usually fight with your partner?____________________ What do you usually fight
about?
________________________________________________________________________________________
_______________________
After fighting do you reconcile with your partner?______________ What did you like about
your partner?
________________________________________________________________________________________
_____________________
Is your partner still studying?____________________ Is he/she in the same school as you?
______________________ If he or she is, do you go to the same college department?
_________ Would you consider marrying your partner?____________ Are you already
married to your partner?_____________ How many years or months have you been
married?________________________

WORKMATES
Are you close with your workmates?________ Do you often interact with them?__________
Do they usually talk with you?___________ Are they nice to you?____________ Do you
often have problems with your workmates?_____________ About what?
____________________________________________________________________________
________________________________________________________________________________________
_______________________________
Does your workmate knows how you feel?______________ Did you attempt to let them
know?_______________
Are you satisfied with how they treat you?_______________ Do you want to be close with
them?_____________
Do you think that its important to be close with your workmates?________ Why/ why
not?_________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________
Do your workmates pressure you during working hours?______________ What usually
gets you pressured during your shift?
________________________________________________________________________________________
__________
________________________________________________________________________________________
_______________________________
Does your supervisor/secretary knows about this?____________ Are you willing to share
this /with him/her__________________ Do your workmates lend you a helping hand with
problems relating to your work?____________ What about problems unrelated to your
work, do they help you as well?________________
Do you feel comfortable working with your workmates?___________ Why/why not?
________________________
________________________________________________________________________________________
_______________________________
Are your workmates mostly boys?____________________ Are your workmates mostly girls?
____________________
Do you feel comfortable with them?________ Do you feel any sense of awkwardness
towards them?_______
Why/why not?
________________________________________________________________________________________
_____________
________________________________________________________________________________________
_______________________________
Do you usually confide to your workmates some of your personal problems?_________
Do they give you advice?________ Do you usually confide to your workmates problems
about your studies?__________________
Do they give you advice?____________ Are you contented with the kind of workmates
that you have right now?_____________ Do they grant you favors when you ask for
them?___________ What favors do you usually ask from your workmates?
_______________________________________________________________________________
________________________________________________________________________________________
_______________________________

OTHER PEOPLE/IN THE WORKING ENVIRONMENT

Do you socialize with other people?__________ Do you usually initiate a conversation

with them?__________
Do they pressure you in doing your work?__________ Are you close with some of them?
____________ Are they nice to you?_____________ Do you think that youre being nice to
them?___________________________________
Do you keep a strictly professional relationship with them?_________ Would you have
liked to get close with them?_______________ Are you comfortable with them?
____________ Do they interact with you for a non-work related matter?___________ Are
you comfortable with that?_____________ Do you usually feel awkward towards them?
____________ Do you have someone/people whom youre close with from your working
environment, not necessarily your supervisors or workmates?____________ Do you
usually interact?___________ What do you usually talk about?
____________________________________________________________
________________________________________________________________________________________
_______________________________
Do you think that people from your working environment are satisfied with your work?
__________________
Why/why not?
________________________________________________________________________________________
______________
________________________________________________________________________________________
_______________________________
What do you think can you do to improve this?
_________________________________________________________________
________________________________________________________________________________________
_______________________________
Do people always call you strict?________ Do they see you as an unapproachable type of
person?__________
Did you make steps in improving that?___________ What did you do to improve that?
________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________

PART IV: YOUR ENVIRONMENT

Instruction: Answer the questions HONESTLY. Check ( ) the appropriate box for your
answer.

WORKING ENVIRONMENT

WORST NEEDS SATISFACTO GOOD EXCELLEN

IMPROVEMEN RY T
T
Computer
Office supplies
(paper clips,
stapler,
bondpapers,
etc.)
Airconditioner/s
Printers
Microphones, if
any
Projectors
Whiteboard
pens, chalk
Record-filing
Desk
Cabinets.
drawers
Size of office
Lockers, if any
Desktop mouse
Telephone lines
School/departme
nt pamphlets
Prospectus
Desktop OS
(Operating
System)
Internet speed

What do you think needs improvement the most from the list?
_______________________________________________
________________________________________________________________________________________
_______________________________
Why?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________________________________
Are you satisfied with your working environment?_______________ Why/why not?
____________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_____
Does your working environment cause you stress or uneasiness?____________ Why/why
not?______________
________________________________________________________________________________________
______________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________
SCHOOLING ENVIRONMENT

WORST NEEDS SATISFACTO GOOD EXCELLEN

IMPROVEMEN RY T
T
Computers
Computer
laboratories
Classroom desks
Cafeteria/s
White or
blackboards
Microphones, if
any
Projectors
Whiteboard
pens, chalk
Classroom
designs
Classroom lights
Airconditioner/s
Size of
classroom
Class gym
Uniform
School ID
Schoolworks
School activities
Internet speed
Lockers, if any
School bus
School museum,
if any

What do you think needs improvement the most from the list?
_______________________________________________
________________________________________________________________________________________
_______________________________
Why?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________________________________
Are you satisfied with your working environment?_______________ Why/why not?
____________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_____
Does your working environment cause you stress or uneasiness?____________ Why/why
not?______________
________________________________________________________________________________________
_____________________________
________________________________________________________________________________________
________________________________________________________________________________________
______________________________________________________________