Name (optional) __________________________________________________

School: _________________________________________________________

Online Learning Modality:

_____ Moodle
_____ Blackboard
_____ Schoology
_____ Google Classroom
_____ Canvas by Instructure
_____ D2L Brightspace
_____ Absorb LMS
_____ LearnDash
_____ CertCentral
_____ Edmodo LMS
_____ Google Classroom
_____ NEO
_____ Others (please specify: __________________)

Type of Internet Connection:

_____ Dial-up/Analog
_____ Digital Subscriber Line (DSL)
_____ Cable Internet Access
_____ Fiber Optic Broadband
_____ Wireless Broadband
_____ Satellite and Mobile Broadband
_____ Cellular

Internet Service Provider:

_____ PLDT
_____ Globe
_____ Converge
_____ Sky Cable
_____ Dito Telecommunication
_____ Others (please specify: _________________)

Number of Tardiness During Synchronous Classes:

_____ 0
_____1-3
_____4-6
_____7-9
_____ 10 and above

Number of Absences During Synchronous Classes

_____ 0
_____1-3
_____4-6
_____7-9
_____ 10 and above

The following are statements about your study habits. Please put a check mark () under
the column that applies for you.
Always Often Sometimes Seldom Never
a. I follow a schedule
for my study time.
b. I create a pre-
studying checklist.
c. I have a study
plan.
d. I study offline as
much as possible.
e. I make sure that I
have a conducive
environment for
studying.
f. I take notes
properly during
class.
g. I take naps during
class.
h. I look at my
cellphone or send
text messages
during class.
i. I space out during
class.
j. I am outspoken
during class.
k. I ask teachers for
help.
l. I religiously keep
track of my
assignments and
deadlines.
m. I test myself
knowledge
periodically.

The following are statements about your submission of outputs. Please put a check mark
() under the column that applies for you.

Strongly Agree Neutral Disagree Strongly

Agree Disagree
a. I regularly
complete all of my
task on time.
b. When I complete
the task that was
assigned, I find
that I have a better
understanding of
the material.
c. I complete my task
if I understand how
to complete it.
d. I only complete
tasks for the
classes that I am
interested in.
e. I regularly
complete task for
my least favorite
class.
f. I believe that
submitting tasks is
 valuable.
g. I find doing
requirements very
interesting.
h. Doing school
requirements are
much too
challenging for me.
i. School
requirements are
too easy.
j. Doing school
requirements is a
waste of time.
k. I do not have the
time to do my
school tasks.
l. I have family
commitments
which prevents me
from completing
school tasks.
m. I make sure that
my school
requirements are
done perfectly.

The following are statements about your attendance in synchronous classes. Please put a
check mark () under the column that applies for you.

Strongly Agree Neutral Disagree Strongly

Agree Disagree
a. I need an alarm
clock to wake me
up for school.
b. A parent or
guardian wakes
me up for school.
c. I show up early.
d. I attend classes
regularly.
e. I do not come to
class late.
f. I find attending
classes very
interesting.
g. I have difficulty
 attending classes
because of
technical
problems.
h. I have other
responsibilities to
attend which
prevent me from
attending classes.
i. I feel like my
attendance is not
checked and does
not matter.
j. I am not motivated
to attend
synchronous
classes.
k. I feel
uncomfortable
facing my
classmates and
teachers on the
camera during
classes.

The following are statements about your class participation. Please put a check mark ()
under the column that applies for you.

Strongly Agree Neutral Disagree Strongly

Agree Disagree
a. I ask questions
during classes.
b. I like to gossip with
my classmates or
someone else
during classes.
c. I do some readings
from my previous
lessons to prepare
for my next class.
d. I do some advance
readings to
prepare for my
next class.
e. I take notes during
classes.
f. I think about other
things while I am
on class.
g. I give my opinion
during discussion.
h. I do school task for
another class
during class hours.
i. I am always
focused on the
instructor.
j. I listen when my
classmates ask
questions.
k. I prepare
discussion
questions or points
of clarifications to
ask.
l. I write up ideas for
questions.
m. I give opinion or
example to further
class discussion.
n. I am active during
group activities.
o. I participate fully in
class activities.

The following are statements about the challenges encountered with regard to online
learning modalities. Please put a check mark () under the column that applies for you.

Strongly Agree Neutral Disagree Strongly

Agree Disagree
a. It is difficult to
adjust with this
new learning style.
b. I need to fulfill
other
responsibilities at
home.
c. There is poor
communication or
lack of clear
directions from
teachers.
d. There is a lack of
 physical space
conducive for
studying at home.
e. We have
unreliable or no
internet access.
f. I am experiencing
mental health
difficulties.
g. I do not have
enough technical
skills.
h. I need to work for
extra income.
i. I have a limited to
no access for
device.
j. Our family lacks
basic needs to
survive.
k. There is a lack of
time for academic
advice from
teachers.
l. Course materials
are not always
delivered on time.
m. Teachers do not
know how to teach
online.
n. There is a difficulty
contacting
academic or
administrative
staff.
o. There is a lack of
timely feedback
from instructor.
p. There is a lack of
access to
teachers.
q. Materials or
instructions online
have lower quality.
r. Class size is not
right for online
learning.
s. There is lack of
interaction or
 communication
among learners.
t. I prefer to learn in
person.
u. I am afraid to use
new tools for
online learning.
v. I am unfamiliar
with online
learning tools.
w. I am not motivated
for online learning.
x. There is a lack of
support from my
family.
y. There are
significant
interruptions
during online
classes.
z. There is
inadequate
technical
assistance for
students.