SURVEY QUESTIONNAIRE

DEAR RESPONDENTS,

We are a HUMSS students in grade-12 level at Pantay Integrated High School. We are working on
the research of “ Impact of Discrimination to the Mental Health of Students in Pantay Integrated High
School. May we request to answer the questions on the survey questionnaire. The information you will
provide will enable our group to attain the purpose of the study. Thankyou for your cooperation.

Researchers

Name: (optional)

Age: 12-14 ◻️ 15-17 ◻️18 and above ◻️

Gender: Lesbian ◻️Gay ◻️Bisexual ◻️Transgender ◻️Queer◻️
Directions: For each statement on the survey, please indicate how much you agree or disagree
with the statement by putting check in the box on the right side of the statement. Your answers
will be kept confidential.
Scale: 5- Strongly Agree
4- Agree
3- Neutral
2- Disagree
1- Strongly Disagree

DISCRMINATION 5 4 3 2 1
1 Heard, saw, read others making fun of your
gender.
2 Been stared or pointed in public.
3 Been called names with your identity used as an
insult.
4 Heard that people don’t like you, don’t belong
into the society.
5 Asked inappropriate, offensive or overly personal
questions.
6 Dropped out of an organized school sport

7 Exclusion/Rejection
 8 Discrimination in the Media.
9 Discrimination at School.
10 Threat/ Aggression

MENTAL-HEALTH 5 4 3 2 1
1 Afraid of socializing
2 Experience suicidal thoughts
3 Currently having anxiety
4 Eating Disorder
5 Feeling Unconfident
6 Been thinking unclearly
7 Giving self-doubt
8 Has ongoing depression

9 Lack of positive thoughts

10 Dealing with problems well

SELF-ASSESSMENT QUESTIONNAIRE
Discrimination ( BULLYING, VERBAL ABUSE, PHYSICAL ATTACK, SEXUAL ASSAULT,
HARRASMENT)

Mental Health/ Emotional Well- Being ( DEPRESSION, ANXIETY, PANIC ATTACKS, SLEEP
PROBLEMS, EATING DISORDER, SELF HARM, ALCOHOL/DRUG PROBLEM)