APPENDIX A

SAMPLE QUESTIONNAIRE

PART A: RESPONDENT BACKGROUND

Instruction To Interviewer: Please check (√ ) the respondent's answer in the provided

spaces.

Name: _____________________________

1. Gender: Male ______ Female _____

2. Age: _____

3. How many years have you been living in the community? _____

PART B: HEALTH PROMOTION & EDUCATION EXPOSURE

4. Did you get involved in health promotion activities on dengue in your community?

YES _____ NO _____

5. What type of health promotion activities did you get involved in your community?

Public _____ Lecture _____ Individual Advice _____

Demonstration _____ Small Group Discussion _____

6. How many times did you get involved in above activities?

______ times

7. Did you receive information on dengue?

YES _____ NO (proceed to Part C) ______

8. What sources of the information on dengue were you exposed?

Public Announcements _____ Printed Media _____

 Newspaper [Local/National] _____ TV [Local / National] _____

9. How many times were you exposed to the above information?

_____ times

10. After encountering the health information and promotion on dengue, how many days

did it take you to engage in dengue prevention activities onyour own?

_____ day(s)

PART C: KNOWLEDGE ON DENGUE

Instruction to Interviewer: Please read the questions clearly and then tick the answers

given by the respondents in the provided spaces.

11. How is dengue fever transmitted to a person?

_____ Mosquito bite _____ Airborne _____Don't know / Others

_____ Blood transmission _____ Waterborne

12. When is usually Aedes active to bite?

_____ 6am - 8am only _____6am-8am & 4pm-9pm

_____Other times or don't know

13. What steps do you take to prevent dengue fever transmission during the outbreak?

_____Cover tightly all water container _____Bury unused tires, if any.

_____Keep drain free from blockage _____Adding larvacide in water containers

_____ Change water in plant container _____Remove water from flower pot trays

_____ Change water in trays under the fridge

_____Place all garbage that can accumulate water into closed bin

_____Level defective floor surfaces that can collect water, if any.

_____Use mosquito repellent and mosquito net when sleeping

_____Destroy / burn unused containers _____Others (please specify) ____________

14. What you must do during the biological / chemical prevention activities take place?

_____Allow inspection of mosquito larvae inside and outside the house

_____Allow the Health Authority to put larvacidals in potentially breeding sites

_____Allow the Health Authority to do fogging inside and outside house

_____Open house windows during the fogging process

_____ Others (please specify) _______________

15. Ano ang ginagawa mo kapag nagka lagnat ka habang may pagsiklab ng dengue?

_____ Mag hanap kaagad ng medical na atensyon / gamutan

_____ Gamitin ang gamot na inireseta matapos magpatingin sa doctor

_____Iba pa (pakitukoy) _________________________

PART D : BEHAVIORAL SELF-EFFICACY

Panuto: Paki rate ng antas ng kumpyansa sa sarili ng respondents sa

nakalahad na kahon sa pamamagitan ng pag check(✅) ng mga pahayag sa ilalim

ayon sa sumusunod na scales .

Katanungan Palagi Madalas Minsan Bihira Hindi

Kailan

man

16. Kaya kong palitan and tubig

sa paso kada linggo.

17. Kaya kong linisin ang lagos

mula sa bara kada pitong

araw.

18. Kaya kong takpan ng

mahigpit ang lahat ng

lalagyan ng tubing sa loob at

labas ng bahay.

19. Kaya Kong kumbinsihin ang

aking mga anak na ilagay

lahat ng basura sa

nakasaradong basurahan .
20. Kaya kong pumunta o

dalhin ang miyembro ng aking

pamilya para magpatingin kaagad

sa doctor kapag ako o sila ay

nagkasakit.

20. Kaya kong palitan ang tubig

sa lalagyan sa ilalim ng

refrigerator kada linggo.

21. Kaya kong payagan ang

awtoridad sa kalusugan na ipa
hamog at inspeksyunin ang
aking bahay anumang oras.
22. Kaya kong kumbinsihin ang

aking kapitbahay na gumawa

ng linggo-linggong

paghahanap at pagsira ng

kahit anong potensyal na

pugad paramihan ng lamok sa

labas ng bahay .

23. Kaya kong maglagay ng

larvacide sa lahat ng lalagyan

ng tubig sa loob ng bahay ko.

24. Kaya kong utusan ang aking

pamilya na matulog sa loob

ng kulambo kada gabi.