Greetings!

We are the researchers from Grade 11 STEM Q and we are currently taking the course, Statistics and Probability 1.
As a partial requirement of the course, we are conducting a study about Senior High School learners' lack of sleep and the
status of their health.

Rest assured that all of your answers will be treated with utmost confidentiality. If you consent to the survey, please put your
signature on the line below. If not, return the paper to the researchers.
Signature: _______________
Full Name (Optional): Age: Sex: Grade: G11 G12

Check (/) the appropriate box that corresponds to your answer. Strand: ABM STEM HUMMS TVL GAS
1. Usually, how many hour/s of sleep do you get at night? ____hour/s

2. How do you rate the quality of your sleep? Please check the appropriate box below.
Poor Fair Good Very Good

3. How satisfied are you with your sleep? Please check the appropriate box below.
Not Satisfied Slightly Satisfied Satisfied Very Satisfied

4. How satisfied are you with the consistency of your sleep? Please check the appropriate box below.
Not Satisfied Slightly Satisfied Satisfied Very Satisfied

Rate the following statements about the things you do before you sleep. Check (/) the appropriate box that corresponds to
your answer. Use the legend below.
1 - Never 2 - Rarely 3 - Often 4 - Always
DESCRIPTION 1 2 3 4

I do my assignments.

I play online games.

I watch television.

I video call my friends/family.

I read wattpad/ novels.

I scroll through social media.

I paint.

I review for quizzes/tasks.

I take a shower.

I do my skincare routine.
I read the wiki and do advanced reading.

I wash the dishes.

I feed my pet/s.

I do my milestones/ final outputs.

I watch movies/ series.

Rate the following statements about the factor/s that affect your sleep. Check (/) the appropriate box that corresponds to your
answer. Use the legend below.
1 - Strongly Disagree 2 - Disagree 3 - Agree 4 - Strongly Agree
FACTORS 1 2 3 4

I can't sleep with the lights on.

I have insomnia.

I can't sleep if my surroundings are noisy.

I can't sleep if it's cold.

I can't sleep if the temperature is hot.

Rate the following statements about your well-being. Check (/) the appropriate box that corresponds to your answer. Use the
legend below.
1 - Never 2 - Rarely 3 - Often 4 - Always
DESCRIPTION 1 2 3 4
PHYSICAL

I find myself feeling very tired.

I easily get sick.

I get tired of performing in school.

I don’t have energy.

My body hurts.

I feel numb.

I easily get burned out.

My eyes feel drained and heavy.

My eyes twitch.
EMOTIONAL

I easily space out.

I have mood swings.

I easily feel frustrated.

I experience stress.

I easily cry.

I feel overwhelmed.

I lost interest in other things.

I’m absentminded.

I feel sleepy in the morning.

MENTAL

I’m having trouble focusing.

I forget things easily.

I feel dizzy after waking up.

I experience anxiety.

I get nervous.

I feel depressed.

I have a short attention span.

I overthink a lot.

I have hallucinations.