CENTRAL PHILIPPINES STATE UNIVERSITY

Kabankalan City, Negros Occidental

OFFICE OF THE GRADUATE SCHOOL
Graduate Studies

SURVEY FORM

Name (Optional): ________________________________________

Age: _____________
Sex: _____________
Grade Level: _________

This questionnaire is made to answer the following questions regarding the study of Miss
Marjoy Barbon about the Stepping Strategies for Grade 5 and 6 Learners Who Are at Risk in
This Distance Learning at Don Galo Elementary School.

Your honest answer and expertise are highly appreciated.

1. What are the electronic gadgets available in your home that you can use to attend during this
distance learning? Please check all learning devices available at your home.

____ TV ____ BASIC CELLPHONE

____ SMARTPHONE ____ DESKTOP
____ LAPTOP

2. Do you have internet connection at home?

____ YES ____ NO

3. How do you connect in an internet?

____ Mobile Data _____ WIFI Satellite

4. What is the mode of your modules?

____ Digitized Modules _____ Printed Modules

5. Where is the location of your house?

____ Inside Brgy. Don Galo _____ Outside Brgy. Don Galo

If outside Brgy. Don Galo, please state the exact address: _______________________________