SURVEY INSTRUMENT

Dear Respondents,

The researcher is conducting a study entitled “COVID-19 PANDEMIC CHALLENGES AND

Use of all personal information collected from this survey form will be used for the purpose of to
knowing the mental health status as IBA LGU Employees as you have experienced being in the frontlines
during the onslaught of the pandemic and to develop a program that would assist you with your mental
health and well-being.

By accomplishing the form, you agree to the collection and use of information in accordance
with the Data Privacy Act of 2012 (RA 10173). Rest assured that all information collected will be kept
confidential and will be used solely for the purposes stated above.

Sincerely,

KDEGUIA

PART 1 EMPLOYEE PROFILE

PROFILE RESPONDENTS

o 20-30
o 31-40
o 41-50
o 50-Above

SEX

o Female
o Male

EDUCATIONAL ATTAINMENT

o Highschool Graduate
o College Graduate
o Masteral Degree with Units
o Masteral Graduate
o Doctorate Degree/Graduate
o Others

NUMBER OF YEARS IN SERVICE

o 0-6 months
o 6 months- 1 year
o 1 years- 3 years
 o 3 years and above

CIVIL STATUS

o Single
o Married
o Widowed
o Separated

MONTHLY INCOME

o 5000-10,000
o 10,000-20,000
o 20,000- Above

POSITION

o Job order
o Contractual
o Contract of Service
o Regular

PART 2 FACTORS OF COVID 19 PANDEMIC

Please check ( ) opposite to each item indicator on your agreement towards the independent
variables guided by the following legends.

1- Strongly Disagree 3- Agree

Statement Indicators 1 2 3 4
(SD) (D) (A) (SA)
PERSONAL Experience in Covid-19 Pandemic
1. I have avoided going out to public places (shops, parks)
because of the fear of contracting coronavirus (COVID-19)
2. I have checked myself for symptoms of coronavirus
(COVID-19)
3. I found it difficult to fall asleep
4. I am worried that our healthcare system is unable to keep
me safe from the virus
5. I am worried that I can’t keep my family safe from the virus
6. I am worried about pharmacies running out of medicines
7. I am worried that if someone coughed or sneezed near me,
I would catch the virus
 8. I am worried that I can’t keep my family safe from the virus
9. I am always visiting social media for Covid -19 virus
updates
10. I have avoided going out to public places (shops, parks)
because of the fear of contracting coronavirus (COVID-19)

Statement Indicators 1 2 3 4
(SD) (D) (A) (SA)
SOCIAL Experience during COVID-19 Pandemic
1. I have no interest doing work or leisure activities.
2. I am worried that social distancing is not enough to keep
me safe from the virus
3. I prefer staying at home browsing social media's than
going outside
4. I am worried that foreigners are spreading the virus in my
country
5. I am worried that if I touched something in a public space
(e.g., handrail, door handle), I would catch the virus
6. I always bring alcohol and facemask whenever I go out to
meet some friends
7. I am worried that people around me will infect me with the
virus
8. I am worried about coming into contact with foreigners
because they might have the virus
9. Canceling life plans e.g. weddings and trips
10. I spend my time doing outdoor exercise rather than
meeting friends

Statement Indicators 1 2 3 4
(SD) (D) (A) (SA)
ORGANIZATIONAL Experience during COVID-19 Pandemic
1. I am productive working from home as I am in my normal
working environment
2. I have everything I need to do my job while working from
home.
3. I feel that my organization has done a great job with
internal communication regarding the coronavirus/COVID-
19.
4. My employer provides sufficient opportunities for internal
 career advancement even if its pandemic
5. Overall, I am satisfied with my organization's response to
the Coronavirus/COVID-19 situation.
6. I can collaborate with other employees effectively even as
we endure high levels of disruption in both work and home
environments.
7. I feel supported in my organization to grow and develop
even if its pandemic
8. I am happy that my organization maintained adequate
communication with all of its employees (even WFH).
9. I am happy about the work life balance proposed by our
organization during pandemic
10. I fear other employees would get infected if we have
meetings and gatherings in our offices

Statement Indicators 1 2 3 4
(SD) (D) (A) (SA)
EMOTIONAL Experience during COVID-19 Pandemic
1. I always feel low (not happy) about the situation this
pandemic
2. I have fear of losing relative during pandemic
3. I feel the future, after COVID is hopeless and that things
cannot be improve
4. I feel I have nothing to look forward to, after COVID
5. I feel discouraged about the future, after COVID
6. I always feel lethargic and emotional during pandemic
7. I feel depress and hopeless
8. I feel frustrated about not being able to do what I usually
enjoy
9. I have a feeling that the future seems darker and scarier
before
10. I feel so anxious about this COVID-19 pandemic

Statement Indicators 1 2 3 4
(SD) (D) (A) (SA)
BEHAVIORAL Experience during COVID-19 Pandemic
1. I am slightly more irritated now than usual, after COVID
2. I have changed my dietary habit and lifestyle than usual
because of this pandemic
3. I am worried that people around me will infect me with the
virus
 4. I had trouble concentrating because I kept thinking about
the virus
5. I had trouble sleeping because I worried about the virus
6. I feel that I am becoming less productive than before
7. I feel angry and irritated easily since Pandemic started
8. I am doing volunteer work during pandemic
9. Having conflicts due to disagreements on how to behave
regarding COVID-19
10. I become engage in unhealthy habit this pandemic

Statement Indicators 1 2 3 4
(SD) (D) (A) (SA)
RESEARCH/ADVISER
Experience during COVID-19 Pandemic
1. I am not interested researching some studies because of
COVID-19.
2. I have fear in interviewing individuals for some research
because of Covid-19.
3. I have low resources of information on research during
pandemic due to travel restrictions and close
establishments.
4. I have low respondents during pandemic that can be used
for our research.
5. I am worried that I might catch the virus from going to one
places to another.
6. Individuals’ information become hard to trace because
some people lies about what they feel during pandemic
7. Some employees/researchers are facing a shortage of
materials or lack of supply
8. Reduce economic activity and employment makes hard to
gather information to some participants in research
9. I used more web-based surveys or secondary data analysis
10. Online survey questionnaire is hard for other respondents