QUESTIONNAIRE

This questionnaire survey aims to assess the community outreach

program of selected dental schools in the Philippines. The result of the survey
will help the researcher answer the stated problems of the study.

Part I.
Direction: Please check the item which appropriately describes you.

1.1 Gender ____ male ____ female

1.2 Age ____ 4-10 ____ 11-17 ____ 18-24 ____ 25-31 ___ 32 -39

___40-46 ___47-53 ___ 54-60 ___ 61 and older

1.3 Civil Status ___ single ____ married

_____ separated ____ widow

1.4 Religion _____ catholic ____ protestant

_____ Iglesia ni Cristo

____ others, please specify _______

1.5 Highest Education Attained ____ preschool ___ elementary

____ high school ____ college ____ graduate studies

1.6 Occupation
____ student ____ faculty

____ dentist ____ barangay official/ leader

____ school personnel

____ others, ( please specify )

1.7 Affiliation

___ community ___ establishment ___ institution

____ dental college

Part II. Please check the appropriate box according to the rating below.
 5- Strongly agree
4 - Agree
3 - Minimally agree
2 - Disagree
1 - Strongly disagree

Objectives 5 4 3 2 1
1. The program objectives adhere to the present
problems of the community.
2. The objectives of the program are clear and
practical.
3. The objectives of the program have been
achieved.
4. The objectives of the program answered the
needs of the beneficiaries.
Implementation
1, Program always starts on time
2. The program was implemented properly and
orderly.
3. The program was conducted in an appropriate
venue.
4. The community was well informed of the activity
ahead of time.
5. There is sufficient time allotment for each
activity.
Management
1. The program is well- planned.
2. The beneficiaries participate in the planning of
activity.
3. Organizers follow the schedule of activity
4. There is a close coordination between
organizer and community coordinators.
5. School officials are actively involve in the
different program of activities
6. Administrators/ facilitators are readily available
when needed.
Facilities / Resources/ Logistics
1. The venue of activity is clean and well-
organized.
2. The venue is sufficient in accommodating the
beneficiaries of the program
3. Instruments and armamentarium area
complete and readily available.
4. Emergency equipments are readily available.
5 4 3 2 1
5. There is sufficient resources (funds) available
 To deliver the program
6. Intersectoral units provide additional support
for the program.
Training
1. Fieldwork preceptors are highly competent
knowledgeable.
2. Faculty updates regularly with current trends
and innovations.
3. Faculty regularly attends seminars and
training to enhance skills.
Evaluation activity
1. Uses evaluation tools every after activity
2. Evaluation is done regularly.
3. Results of evaluation is readily interpreted to
improve program.
4. Evaluation tool is widely distributed among
The beneficiaries of the program.

Part 3 Please check the appropriate line corresponding to the answer.

What are the problems of the community outreach program?

__ lack of funds (resources,etc.)

___ Lack of staff

___ lack of coordination among staff and community

___ lack of training of staff

___ disorganized outreach activity

___ lack of outreach activity

___ lack of evaluation tool

___ other. Please specify_______________________