Sample Survey Questionnaire

Name: (optional)____________________________________
Age: ________

Year Level:

1st year

Gender:

Male

Female

2nd year

Course: ________
Student status: Student with failed grade
Instruction: Which of the following problems do you experience? Indicate the problems you encountered
by putting a check () in appropriate boxes.
PERSONAL FACTORS
I have difficulty gaining friends.
I am sickly.
I wanted to be alone by myself.
I am not ready for high school.
I am engaged in different vices (eg. Alcoholism,
gambling and illegal drug use)
6. Im into fraternities / gangs.
7. Lack of motivation to study.
8. Lack of self-confidence.
9. I have no one to talk about my school problems.
10. I got pregnant / I have a child
FAMILY FACTORS
1. My parents do not support me.
2. I came from a broken family.
3. I dont have enough allowance.
4. I always have fights with my siblings.
5. I have to work and earn money for the family.
6. I didnt grow up with my parents.
7. lack of communication with parents.
8. I experienced physical abuse from my family.
9. I cant study at home because of poor home condition.
10. I have excessive family responsibilities.
SCHOOL FACTORS
1. I have difficulty understanding the lessons discussed
by the teacher
2. School works are too hard for me.
3. Absenteeism of teachers.
4. Poor school facilities.
5. Overcrowded classrooms
6. My schoolmates bullied me.
7. My teachers are too traditional and boring.
8. I am not interested in attending classes
9. Lack of books and other school materials.
10. My teachers have unpleasant attitude and inconsiderate
in students.

YES

NO

YES

NO

YES

NO

1.
2.
3.
4.
5.