Region 1

Schools Division of Ilocos Norte

BAGBAG SOLSONA NATIONAL HIGH SCHOOL
Senior High School
Solsona

Instruction: Please fill out the necessary information asked below. Put a checkmark on the box
provided. Any information that will be gathered will be treated with utmost respect and confidentiality

PART I. Socio-demographic Profile

Name (Optional): _____________________________________

Age: _________

Sex: Male Female

Family Income (Monthly): ₱5,000-₱10,000 ₱15,000-₱20,000 ₱20,000 and above

Type of family: Nuclear Family (living with mother, father, and children)

Blended Family (living with mother, father, and two or more children
which one is adopted)

Extended Family (living with several generations of people like uncle,

auntie, and grandparents)

Single-parent Family (living with only mother or father)

PART II. Factors that Affect the Behavior Problems of Students

Instruction: The following items describe statements about the factors that affect the behavior
problems of students. Indicate your responses with the following statements by putting a checkmark
that corresponds to your answer.

Always- 5 Frequently- 4 Sometimes- 3 Seldom-2 Never- 1

Always Frequently Sometimes Seldom Never

FAMILY FACTOR
5 4 3 2 1
I talk about things with my family and
share problems with them.
My family provides for all my needs.
My family and I share time together.
I can easily express what I feel.
My family supports me every time.

Always Frequently Sometimes Seldom Never

PEER FACTOR 5 4 3 2 1
I do not want to miss my classes,
even if my friends asked me to do it.
I avoid doing things that my friends
told me to do.
I stay away from my friends that do
violent actions.
I refuse when my friend requested
something that I don’t like to do.
I don’t do things just to please people
to accept me.
Always Frequently Sometimes Seldom Never
EMOTIONAL FACTOR
5 4 3 2 1
When I’m upset, I make myself busy
to divert my attention.
I can relate to the experience that
was shared by my classmates.
Once I am experiencing negative
emotions, I try to find time to reflect
on the things that I have done.
When I am feeling positive emotions,
I am careful in expressing them.
When I am experiencing a stressful
situation, I make myself think about it
in a way that helps me stay calm.
Always Frequently Sometimes Seldom Never
ENVIRONMENTAL FACTOR 5 4 3 2 1
I choose to not meddle in a situation
that I’m not aware of, as a show of
respect.
I am more hands-on and focused on
my studies when I am alone.
I visit quiet areas like libraries to
unwind and make my mind at ease.
I adjust myself when I am in another
place or environment.
I am aware when a circle of friends
doesn`t want my presence.