SAMPLE RESEARCH INSTRUMENT

Research Title: “EVALUATION OF TAYABAS WESTERN ACADEMY’S READING PROGRAM

FOR GRADE 7 LEARNERS, S.Y. 2021-2022: MULTI-PERSPECTIVE SURVEY”
Researchers: Rosco, Rhodora P. and Dela Cruz, Ma. Blesil P. (Major in English)

Brief Description and Purpose of the Research Instrument:

This part consists of the research instrument serving as a tool to collect Information and
data that was necessary to this study. The researchers used the survey-questionnaire form which
led to get information and data that helps for this study. It contained the following: 1. Profile of
the respondents. 2. The result of reading level of the learners in pre-test and post-test of RACE
program. 3. Perceived factors affecting the reading performances of the learners.

I. GENERAL DIRECTION
The researchers utilized the survey-questionnaire which aims to answer the
research questions by the respondents, which could lead to create the findings and
conclusions that are seen in chapters 4-5.

II. DATA PRIVACY POLICY AND RESEARCH ETHICS

All data gathered in this research instrument will strictly follow the provisions of
the Data Privacy Act of 2012 and will be stored, analyzed, and used exclusively for
the purpose of the research. The principles of research ethics will be adhered
throughout the conduct and process of the research.

III. PART I OF THE INSTRUMENT

Profile of the Respondents

Instruction: Please provide the most accurate information in the following:
Name:____________________________________
Age:______________________________________
Sex:______________________________________

IV. PART II OF THE INSTRUMENT

The result of reading level of the learners in pre-test and post-test of RACE program.
Pre-Test:_______________________
Post-Test:______________________
 V. PART III OF THE INSTRUMENT

Perceived Factors
Instruction: Please put a checkmark (/) in the column provided opposite each item
to signify your answer. Use the scale that follows:

5_______to a very great extent

4 _______great extent

3 _______moderate extent

2 _______ slight extent

1 _______ no extent at all

A. Parent Factor

Item Statement 5 4 3 2 1

1. Sufficient educational support and concern from

parent

2. Obtains proper nourishment needed for their

studies

3. Obtains the needed physical needs form parent

4. Rewards their children whenever they obtain high

grades

5. Keeps children away from family problems and

frequent quarrels which directly and indirectly
affect their studies

6. Gives praises for whatever success their children

 obtain from school

7. Listens to children’s explanations before scolding

and beating them

8. Involve themselves to improve the reading

deficiencies of their children

9. Assists or help their children in preparing

homework

10. Have regular communication with their children as

regards their studies

11. Does not allow their children to go to any place

around instead of studying their lessons at home

12. Attends to their children’s emotional, social,

intellectual, and health needs.

B. Learners Factor

Item Statement 5 4 3 2 1

1. Interested in studying particularly in reading

2. Obtains the proper motivation to read the printed

page
3. Can cope and understand the lessons presented in
Reading

4. Have pre-reading preparation before engaging in

beginning reading activities

5. Have enough low level materials for reading

practice

C. Teacher Factor

Item Statement 5 4 3 2 1

1. Have time to supervise each pupil with reading

disabilities

2. Have enough materials for pupils with reading

disabilities

3. Very focus on the regular work loads

4. Employs/utilizes different methods/strategies of

teaching

5. Have patience to handle pupils with reading

difficulties and disabilities

6. Have enough trainings in handling pupils with

varied reading disabilities
-END-