Survey Questionnaire

Dear Respondents,

Please answer the question truthfully. The data that will gathered from your

answers are confidential thus, it is not revealed publicly.

Thank you.

Direction: Please complete the following information asked and put a check mark on the

box provided.

Part I. Demographic Profile of the Respondents

Name (optional):

Address (optional):

Age:

Gender: Male Female

Civil Status:

Single Married Widowed

Educational Attainment:

Elementary Level

Secondary Level

College Level

How many children in your household?

Part II. Recipients Current Information

Direction. Please answer the following question on the empty box provided.

Name of the Child

Age of the Child

Birthdate of the child

Gender of child

Present Weight of the

Child

Type of Malnutrition

Health services availed

Number of Nutripaks

consumed this month

Part III. The extent of Implementation of Dietary Supplementation

Direction: Please complete the following information asked and put a check mark on the

box provided.

Scale Range Verbal Description

3 2.34- 3.00 Well Implemented

2 1.67- 2.33 Moderately Implemented

1 1.00- 1.66 Not Implemented

Indicators of Dietary 3 2 1

Supplementation WE MI NI

1. Weekly ration of Nutripak given

by BNS to the household

2. Enough supply of NUTRIPAK to

the malnourished child

3. BNS monthly monitored the

nutrition status of the child

4. There is advocacy such as

mother’s class in your barangay.

5. Barangay captain well informed

the importance of supplementary

feeding,
Part IV. Extent of Nutrition and Frequency of Feeding

Direction. Please answer honestly the questions asked by the researcher. The data that

will gathered from your answers are confidential thus, it is not revealed publicly.

1. How many barangay nutrition scholars?

2. Are the barangay nutrition scholars monitored your child’s nutrition status?

3. What have you learned in feeding your child the NUTRIPAK?

4. Can you elaborate hoe you feed your child?

5. How many times does you feed your child?