Santiago City, Isabela, Philippines

Tel/Fax: (078) 682-8256

www.northeasterncollege.edu.ph
QUESTIONNAIRE
“Challenges of Adolescent Mothers in Barangay Rizal”
To the respondents,
Greetings!
We would like to borrow ten (10) minutes of your time to answer our survey
questionnaire for our research study entitled “Challenges of Adolescent Mothers in
Barangay Rizal" This study aims to understand, analyze, and address the specific
issues and factors affecting adolescent mothers.
Please be assured that all personal data will be treated CONFIDENTIALLY and
the answers you provide in this survey will be collected for the sole purpose of the
research study.
The Researchers

Name (optional): ________________________________________

Instruction: Please put a check mark (√) on the answers that would best apply you.
I. Demographic Profile
a. Age:
[ ] 12 years old – 14 years old
[ ] 15 years old – 17 years old
[ ] 18 years old – 19 years old

b. Marital Status: ( ) Single ( ) Married ( ) Widowed

c. Family type: ( )Nuclear ( ) Extended ( )Blended

d. Educational attainment:
( ) Elementary Graduate( ) Junior High School Completer
( ) Senior High School Graduate
( ) Undergraduate

e. No. of children: ( ) 1 ( )2 ( )3 other:

f. Occupation:
 Santiago City, Isabela, Philippines
Tel/Fax: (078) 682-8256
www.northeasterncollege.edu.ph

II. Assessing Personal Challenges

Instruction: Assess and score each of the questionnaire’s statements. Read each
statement and decide how strongly the statement applies to you. Put a check mark (√)
on column corresponding to your response. Score your assessment using a scale:
 1 – Never
 2 – Rarely
 3 – Sometimes
 4 – Frequently
 5 – Everytime
Particulars 1 2 3 4 5
HEALTH

1. I am able to bring my child on a doctor for check up

2. I use herbal medications whenever my child is sick

3. I seek help in barangay health worker when my child is

sick.

FINANCIAL SITUATION

1. I am able to buy the needs of my child.

2. I am supported financially by my parents or partner

3. I have a job I have a business which provide for me and

my child

EMOTIONAL CHALLENGE

1. I have low self-esteem

2. I experience emotional instability.

3. I feel lonely because I have no more friends.

4. I feel unwanted because I was not able to fulfill my

parents will.

5. I feel socially judged.

 Santiago City, Isabela, Philippines
Tel/Fax: (078) 682-8256
www.northeasterncollege.edu.ph
CHILD REARING CHALLENGES

1. I could not provide the needs of my child

2. My child has no father figure growing up

3. I find it difficult to discipline my child

4. I panic whenever my child is sick

5. I lack knowledge in taking care of a newborn

CHILD REARING

1. I could not provide the needs of my child

2. My child has no father figure growing up I find it difficult

to discipline my child

3. I panic whenever my child is sick

4. I lack knowledge in taking care of a newborn

IMPACT

1. I feel omitted in my movements or activities

2. I prioritize the needs of my child before my own needs

3. I am not able to pursue my studies

4. I feel that I am socially isolated

5. I feel that I am an object of gossip

6. I feel that I am the black sheep of the family

7. I did not enjoy my adolescent years

8. I feel that I could no longer find a guy who will marry me

9. I can no longer go out with my friends