A Survey Instrument on

“Implementation of RA 9211 (Anti-Smoking Law)

In Selected Barangay of Caloocan City”

QUESTIONNAIRE

PART I. Personal Profile of the Respondents.

Direction: Kindly put a check (/) mark on the appropriate box provided for the classification of
information needed. Rest assured that all information provided will be treated in strictest
confidentiality.
1. Name : (Optional)______________________
2. Age : v 2 21 – 25 y/o 36 - 40y/o 51 – 55 y/o
26 – 30 y/o 41 – 45 y/o 56 – 60 y/o
31 – 35 y/o 46 – 50y/o 61 y/o & above
3. Gender : Male Female
4. Civil Status: Single Married Others (specify) ______
Widow/er Separated
5. Educational Attainment: Elementary Level Elementary Graduate
High school Level High school Grad
College Level College Grad
w/Masteral Units Masteral Degree
w/DoctoralUnits Doctoral Degree
6. Employment Status: Permanently Employed Unemployed
Part-time Employed Contractual

PART II. Assessment on the Level of Implementation of Respondents on the Anti-

Smoking Campaign of the Government
Direction: Kindly put a check (/)mark on the appropriate column that best describe your
assessment on the Anti-Smoking Campaign of the Government. Refer to the legend for your
assessment.
Legend:
RATING SCALE DESCRIPTIVE RATING
3 Highly Implemented (HI)
2 Implemented (I)
1 Not Implemented (NI)

Implementation of Anti-Smoking Campaign of the 3 2 1

Government
A. Policy
1. Strict compliance on rotation of health warning signages
2. Enforce no selling of tobacco products within perimeters of
youth centers
3. Strict enforcement on smoking ban on public conveyance
4. Full implementation of standards on no smoking areas
5. Enforce no selling policy on minor
 B. Guidelines
1. Clear display of health warningwithn the barangay premises
2. Regular submission of Barangay Health plan
3. Up-to-date notice on prohibition to sell tobacco products on
minor
4. Compliance on required health warnings
5. Enforce designated smoking areas
C. Regulations
1. Compliance to marketing provisions
2. Prohibits giving sample of tobacco products on minor
3. Absolute ban on tobacco company sponsorship on barangay
projects and programs
4. Disposition of outdoor advertisement within restricted zone
5. Clear display of health warnings on designated areas
D. Penalties
1. Institutionalize the criminal proceedings
2. Enforce Authority on City, Municipal and Police officials to
initiate action
3. Strict enforcement on penalties imposed among violators
4. Enforce Authority on Barangay officials to reprimand smoking
violators
5. Provide remediation programs on minors caught smoking

PART III. Assessment on the Challenges encountered in the implementation of RA9211

campaign of the Local Government Unit
Direction: Kindly rank the following challenges you encountered in the implementation of
RA9211 campaign of the Local Government Unit, 1 as most challenging and 10 as the least.

Challenges Rank
1. Strict enforcement on smoking ban on public conveyance
2. Enforce no selling of tobacco products within perimeters of
youth centers
3. Enforce no selling policy on minor
4. Regular submission of Barangay Health plan
5. Clear display of health warning within the barangay premises
6. Enforce designated smoking areas
7. Clear display of health warnings on designated areas
8. Enforce Authority on City, Municipal and Police officials to
initiate action
9. Enforce apprehension on violators of no smoking policy on no
smoking areas
10. Provide remediation programs on minors caught smoking
PART IV. Assessment on the Solutions Proposed on the challenges encountered in the
implementation of RA9211 campaign of the Local Government Unit
Direction: Kindly rank the following solutions recommended on the challenges you encountered
in the implementation of RA9211 campaign of the Local Government Unit, 1 as the topmost
solution and 10 as the least.

Solutions Rank
1. Public information on No-Smoking ban on public conveyance
2. Enforce strict monitoring on designated no-smoking areas
3. Present plan of action on no smoking policy for minors
4. Monitor regular submission of Barangay Health plan
5. Establish a barangay monitoring council for the
implementation of no-smoking policies, guidelines and
regulations
6. Create an exclusive barangay patrol group for apprehension
of smoking violators
7. Establish a barangay smoking council
8. Formulate guidelines on smoking violation penalties
9. Enforce Authority on Barangay officials to reprimand and
penalize smoking violators
10. Design a remediation programs on minors caught smoking

Thank you for your cooperation and time !

-The Researcher-