XAVIER UNIVERSITY – ATENEO DE CAGAYAN

COLLEGE OF NURSING

IN PARTIAL FULFILLMENT FOR THE REQUIREMENTS OF

NCM 111 – NURSING RESEARCH

SUBMITTED BY:

MA. THERESE P. BALLARES

BSN 3 – NB

SUBMITTED TO:

MA. JESSECA P. MONSANTO, RN, MAN

CLINICAL INSTRUCTOR

OCTOBER 3, 2020
 A Research Study Questionnaire
Hi! We are third year nursing students of Xavier University, and are currently conducting a research on Alcohol
Consumption. We want to understand better the variables that lead to the causes of the aforementioned.

Name (optional): _________________________________

Directions: Please read through and answer the questions by leaving check (/) on the boxes provided.
_________________________________
I promise to answer this research questionnaire with honesty. (SIGNATURE)

1. Do you drink alcohol? (If no, there is no need to answer the subsequent questions.)
 Yes  No

2. Are you a male or female?

 Male  Female

3. How old are you?

 0-14 y.o  15-24 y.o  25-64 y.o  65 y.o and above

4. What is your marital status?

 Single  Married  Widowed  Annulled  Separated

5. In doing your daily activities, do you feel stressed, anxious or depressed?

 Yes  No  I’m not sure

6. What is the reason why you consume alcohol?

 Peer pressure  High levels of stress  Act of rebellion
 For fun  No particular reason  Others (please specify): _______________

7. As a kid, were you exposed to alcoholism in the family?

 Yes  No

8. Do you plan on withdrawing from alcohol consumption in the future?

 Yes  No  I’m not sure
 A Research Study Questionnaire
Hi! We are third year nursing students of Xavier University, and are currently conducting a research on online
classes. We want to understand better the variables that lead to the effects of the aforementioned.

Name (optional): _________________________________

Directions: Please read through and answer the questions by leaving check (/) on the boxes provided.
_________________________________
I promise to answer this research questionnaire with honesty. (SIGNATURE)

1. Are you currently studying? (If yes, please specify your year level.)
 Yes, ___________  No

2. If applicable, does your father work? (If yes, please specify his occupation.)
 Yes, ___________  No

3. If applicable, does your mother work? (If yes, please specify her occupation.)
 Yes, ___________  No

4. What do you utilize for your online classes?

 Phone  Laptop  PC  Others (please specify): ___________

5. Do you have internet connection at home?

 Yes  No

6. If yes, do you have problems with the stability of connection?

 Yes  No  Sometimes

7. If no, where do you conduct online classes?

 Internet cafe  Coffee shops  Others (please specify): ___________

8. Do you think you can learn better with online classes as compared to face-to face discussion?
 Yes  No

9. How would you rate your productivity from a scale of 1-5 (1-least and 5-most)?
 1 (not productive at all)
 2 (rarely productive)
 3 (sometimes productive)
 4 (often productive)
 5 (very productive)

10. Did you develop any deterioration in terms of your health while having online classes? If yes, please
choose as many as possible.
 Eye sore
 Back or neck pain
 Mental health deterioration
 Others (please specify): ______________________