Survey Questionnaire-Checklist on COVID-19 Pandemic

at Lila National High School Campus

S.Y. 2020-2021

Name___________________________________________ Date: _______________

(Optional)

I. Respondents Profile: Please put a check on the line for your answers.

Sex: _____Male _____Female

Age: _____12-13

_____14-15

_____16above

II. Direction: Kindly answer the table by checking your answer in appropriate
column.

Yes No

1. Do you follow the safety protocols in your

area/barangay?

2. Does anyone in your area/barangay who has been

infected by the virus COVID-19?

3. (Did or Do) you only leave the house when absolutely

necessary?
4. Do you wear Personal Protective Equipment (PPE)
such as Face shield and Face mask in public places?
5. Are you willing to get vaccinated?