CANDA NATIONAL HIGH SCHOOL- GAD PROGRAM

Needs Assessment Survey and Mental Health Assessment

DATA PRIVACY

Pursuant to Data Privacy Act of 2012, the Department of Education –Canda NHS recognizes the privacy and the security of
your personal information. Rest assured that any information collected will be protected and will only be used for the
purpose of GAD programs in the school which will serve as reference for implementing gender-responsive PPAs.

I. Demographic Profile
Name:___________________________________ Age: ______ Religion:_______ Number of siblings in the family:______
Grade Level:______________________________ Section:____________
Sex Assignment (by birth): □ Male □ Female

Gender Identity (Pagkakakilanlang Pangkasarian)

□ Lesbian (tomboy)
□ Gay (bakla)
□ Bisexual (attraction to members of both sexes)(nagkakaroon ng atraksyon sa dalawang kasarian)
□ Heterosexual (a person attracted to people with opposite sex)(nagkakaroon ng atraksyon sa kataliwas na kasarian)
□ Transgender or trans (gender identity or gender expression differs from the biological sex they were assigned at birth( ang isang tao
ay nakararamdam na siya ay nabubuhay sa maling katawan, ang kaniyang pag-iisip at ang pangangatawan ay hindi magkatugma)
□ Queer (gender identity is outside the strict male/female binary)(mga taong naniniwalang hiwalay na aspekto ng pagiging tao ang
sekswalidad at kasarian)
□ Intersex (a person born with a combination of male and female biological traits) (isang tao na isinilang na may parehong katangiang
panlalaki at pambabae-halimbawa ang isang tao ay may panlabas na ayong pambabae ngunit may panloob na reproductive organ na
panlalaki)
□ Asexual (experiences little to no sexual attraction)(nakakaranas ng kaunti o kawalan ng atraksyon sa anumang kasrian)
□ Pansexual (someone who is attracted to people of all gender identities)(nagkakaroon ng atraksyon sa lahat ng uri ng kasarian)
□ Others (iba pa)

I. Needs Assessment Survey

This portion is a 3-part questionnaire emphasizing the 3 domains in the development of learners namely, personal/ social, and academic
domain. Direction: Please put a check mark (/) on the box appropriate to your response to the information needed below.
A. Personal Domain

Survey Questions Always Often Sometimes Never

(Palagi) (Madalas) (Paminsan- (Hindi
minsan) Kailanman)
I see/heard my parents/guardian/siblings fight verbally or physically or
emotionally.
[Nakikita ko/naririnig ko na nag aaway ang aking mga
magulang/tagapagalaga/kapatid.]
I have experienced abuse such as physical, verbal, emotional or sexual from
my family members.
[Ako ay nakararanas ng pang-aabusong pisikal, verbal, emosyonal or
sekswal mula sa aking pamilya.]
My parents/guardian uses sharp words that hurt my feelings.
[Masakit magsalita ang aking mga magulang/tagapagalaga.]
My parents favor my siblings more than I do.
[Mas pinapaboran ng aking mga magulang ang aking mga kapatid kesa sa
akin.]
My family member/s is/are using prohibited drugs or alcoholic drinks.
[Meron sa aking pamilya na gumagamit ng pinagbabawal na gamot o
nakakalasing na inumin.]

Social Domain

Survey Questions Always Often Sometimes Never

(Palagi) (Madalas) (Paminsan- (Hindi
minsan) Kailanman)
I’ve been rejected from different groups that I want to belong.
[Naranasan ko na hindi mapabilang sa kahit anong grupo na gusto kong
salihan.]
I find it difficult for me to have friends or to belong in a peer group.
[Nahihirapan akong makipagkaibigan o mapabilang sa isang grupo.]
I am attracted to same-sex.
[Naaakit ako sa taong katulad ng aking kasarian.]
I’ve experienced embarrassment every time I share my opinions with others.
[Naranasan kong mapahiya kapag ako ay nagsasalita sa harapan ng
madaming tao o sa klase.]
I am not sure what my gender will be.
[Ako ay naguguluhan sa aking kasarian.]

Academic Domain

Survey Questions Always Often Sometimes Never (Hindi

(Palagi) (Madalas) (Paminsan- Kailanman)
minsan)
I cannot understand the instructions and explanations written in the modules.
[Nahihirapan akong intindihin ang mga nakasulat na instructions at
explanations sa aking mga modules.]
I do not have resources (load, tablet or android phone, ballpen, paper) to
answer the modules.
[Wala akong sapat na kagamitan tulad (load, tablet or android phone,
ballpen, paper) sa pag sagot ng aking mga modules.]
My parents/guardian do not have enough time to get/return my modules in
school.
[Ang aking mga magulang/tagapagalaga ay walang sapat na panahon/oras
sa pagkuha/pagbalik ng aking mga modules sa paaralan.]
I have lost interest in answering my modules.
[Nawawalan ako ng gana sa pag sagot ng aking mga modules.]
I am struggling in too many activities in the modules.
[Ako ay nahihirapan sa pag sagot ng maraming activities ng aking modules.]
I cannot set my priorities between doing leisure activities and answering
modules.
[Hindi ko malaman kung ano ang aking uunahin na gawin, ang pag gawa ng
ibang bagay o pag sagot sa aking modules.]
I find myself easily distracted in non-academic activities (social media, online
games, household chores, personal errands) while answering my modules.
[Madali akong na di-distract sa mga bagay na walang kinalaman sa
academics tulad ng social media, online games at mga gawaing bahay
habang nagsasagot ng modules.]

III. Mental Health Domain

We are humbly asking you to answer this with honesty.

Survey Questions Yes NO

Persistent depressed mood.
[Palagi ka nakakaramdam ng matinding kalungkutan]
Markedly diminished interest in or pleasure from activities.
[Nawawalan ka ng ganang gawin ang ibat-ibang bagay na dati mong normal na ginagawa]
Disturbed sleep or sleeping too much.
[Balisa sa pagtulog o sobra sa pagtulog]
Significant change in appetite or weight (decrease or increase)
[Sobrang gana sa pagkain / walang gana sa pagkain]
Beliefs of worthlessness or excessive guilt.
[Iniisip mo na wala ng saysay ang iyong buhay o may mga hindi magandang pangyayari na pakiramdam
mo ikaw ang dahilan]
Observable agitation or physical restlessness
[Hindi mapakali o madaling mairita]
Talking or moving more slowly than usual
[Walang ganang kumilos o makipag-usap o makisalamuha]
Hopelessness
[Pakiramdam na wala ng pag-asa sa buhay]
Suicidal thoughts or acts
[Iniisip mo na gusto mo ng tapusin ang iyong buhay o sumubok saktan ang sarili]
Do you experienced considerable difficulty in daily functioning in personal, family, social, educational,
occupational and other areas?
[Naranasan mo ba na sobra kang nahihirapan gawin ang mga pang araw araw mong gawain, sa iyong
sarili,makisalamuha sa ibang tao, sa iyong trabaho at iba pang mga bagay bagay.]