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Survey Questionnaire

To our beloved Respondents:

Greetings of Peace!

The researchers are currently enrolled in Holy Cross College of Calinan and are
working on a comparative research about the stress level among Grade 10 and 11 that
are presently enrolled in HOLY Cross College of Calinan.

In this regard, we prepared this questionnaire to gather information that is


relevant to our research.

If so, please fill out the following items honestly. We assure you the
confidentiality of the information that was generated from your response.

Thank you very much!

-The Researchers
Name ____________________________________________________ ____ Date
____________ __ Age ________ Gender (Circle): M F
Grade___________________________

The questions in this scale ask you about your feelings and thoughts during the last month.
In each case, you will be asked to indicate by circling how often you felt or thought a
certain way.

0 = Never
1 = Almost Never
2 = Sometimes
3 = Fairly Often
4 = Very Often

1. In the last month, how often have you been upset 0 1 2 3 4


because of something that happened unexpectedly?
2. In the last month, how often have you felt that you were 0 1 2 3 4
unable to control the important things in your life?
3. In the last month, how often have you felt nervous and 0 1 2 3 4
“stressed”?
4. In the last month, how often have you felt confident 0 1 2 3 4
about your ability to handle your personal problems?
5. In the last month, how often have you felt that things 0 1 2 3 4
were going your way?
6. In the last month, how often have you found that you 0 1 2 3 4
could not cope with all the things that you had to do?
7. In the last month, how often have you been able to 0 1 2 3 4
control irritations in your life?
8. In the last month, how often have you felt that you were 0 1 2 3 4
on top of things?
9. In the last month, how often have you been angered 0 1 2 3 4
because of things that were outside of your control?
10. In the last month, how often have you felt difficulties 0 1 2 3 4
were piling up so high that you could not overcome them?

Information regarding change (Burnout)


Look back over your school experience since you began your current program of study.
Have you been noticing changes in yourself, your family, work, or social situations? Circle
a number from one to five to designate the degree of change you perceive

Circle a number from one to five to designate the degree of change you perceive
I = little or no change (0 -20%)
2 =some change (2 1 - 40%)
3 = moderate change ( 41 - 60%)
4 =much change (61- 80"/o)
5 = a great deal of change (81 -100"/o)

12345 a) Do you tire more easily and feel fatigued rather than energetic?
12345 b) Are people annoying you and telling you that you dont look so good
lately?
I2345 c) Are you working harder and harder and accomplishing less?
I2345 d) Are you increasingly cynical and disenchanted?
l2345 e) Are you often invaded by sadness you can't explain?
12345 f) Are you forgetting things?
12345 g) Are you increasingly irritable, more short-tempered, more disappointed
in the people around you?
12345 h) Are you seeing close friends and family members less frequently?
12345 i) Are you too busy to do even routine things like make phone calls, read
for fun, or send out cards?
12345 j) Are you suffering from physical complaints like aches, pains, headaches,
or a lingering cold?
12345 k) Do you feel disoriented when the activity of the day comes to a halt?
12345 I) Is joy elusive?
12345 m) Are you unable to laugh at a joke about yourself?
12345 n) Do you have little to say to people?

Information about your lifestyle

Read each statement, then decide if the statement is never true for you, seldom true for you, very
often true for you, or almost always true to you.

Check the appropriate answer in the blanks provided.

I = Never 2 =Seldom 3 = Very often 4 = Almost always

(I) (2) (3) (4) almost always


never seldom very
ofte
n
a. At bedtime, I fall asleep easily
b. I get along well in school
c. If awakened. I easily fall asleep again
d. I control nervous habits (e.g. nail)
e. I take 15 to 20 minutes a day to do what I
want
f . I accept things I can't change
g. I get along well with my family

h. I make sure I take time each day to relax


i. I am happy with my life

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