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Teacher-Respondents Profile Questionnaire

To my dear respondents,
Your responses will be treated with utmost confidentiality.
- Dalaguete NHS DRRM Committee
Part I. Socio-Demographic Profile of Teacher Respondents:
Name: ________________________________________________ Gender: _________ Civil Status:_______________
Please check the check box if you are PWD/pregnant/senior citizen.
PWD Pregnant Senior Citizen

Part II. School Information: (Parameters are modified from the template of DRRM Population At Risk SY 2017-2018)
School: School Address:
Name of School Building: Advisory Room Number:
Office Room Number: Designated Area of Concern:
Part III. School Watching Checklist (Some parameters are modified and based from DRRM School Risk Assessment,
Annex 1: School Watching Checklist)

Checklist with specified location of hazard area or object Yes No Location/subject for policy implementation
1. Broken window
2. Slippery pathway
3. Blocked corridor
4. Heavy objects mounted on top of cabinets/shelves
5. Flooded area
6. Busted plugs/light bulbs/electrical facilities
7. Exposed electrical wires
8. Protruding nails in chairs and tables
9. Broken door knobs
10. Warning sign: Slippery pathways/corridors
11. Plants mounted on the building railings
12. Flooding
13. Exposed chemicals and liquids
14. Lack/absence of storage for equipment
15. Unlabeled chemicals
16. Dripping ceiling
17. Open pit
18. Stagnant water
19. Unpruned trees/bushes/shrubs
20. Open/Clogged canals
21. No ramps for elevated school buildings or other facilities
22. Swing-in doors
23. Broken/dilapidated ceiling
24. Open/incomplete perimeter fence
25. Presence of stray animals inside the school campus
26. Presence of electrical post/transformer near or within the
school perimeter
27. No system of release to parents during emergencies
28. No posted emergency hotlines around the school
29. Garbage Area (Segregation of Biodegradable and Non-
30. Detached or peeled off GI sheet
31. Broken toilet bowl and / or sinks
32. Broken chairs/desks/tables
33. Blocked/no emergency exits
34. Unmounted cabinets/shelves
35. Medical kits in every classroom
36. Bells/alarms
37. Condemnable building (i.e. very old structure, collapsing
building and / or prominent cracks on classroom walls)
38. Others, please write them at the back of this sheet

We thank you. God bless us all. Page 1

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