Questionnaire For The Student On Vices

QUESTIONNAIRE FOR THE STUDENTS
Part I. Profile
NAME: (Optional)
Sex: [ ] Male [ ] Female

Age: [ ] 11-12 y.o. [ ] 13-14 y.o. [ ] 15-16 y.o. [ ] 17 y.o. & above
Year Level: [ ] Grade 7 [ ] Grade 8 [ ] Grade 9 [ ] Grade 10
Part II. Please answer the following questions honestly using the rating scale below:
Rating Scale Description/Implication

3.26 – 4.00 A Always/5 times a week during school days
2.51 – 3.25 O Often/3-4 times a week during school days
1.76 – 2.50 S Sometimes/1-2 times a week during school days
1.00 – 1.75 N Never/0 times a week
Please tick the appropriate box.
Statement Always Often Sometimes Never

The vices that I engaged in:
Drinking Liquor
How many times per week did you consume
alcohol? □ □ □ □
Smoking Cigarette
How many times a week did you smoke
cigarettes? □ □ □ □
Gambling
How many times a week did you engage in
gambling activities? □ □ □ □
Online Games Addiction
How frequent did you participate online game
activities each week? □ □ □ □
1. I started vices at age: 11-12 13-14 15-16 17 & above
Drinking liquor [ ] [ ] [ ] [ ]
Smoking Cigarette [ ] [ ] [ ] [ ]
Gambling [ ] [ ] [ ] [ ]
Drug Addiction [ ] [ ] [ ] [ ]
Online Games Addiction [ ] [ ] [ ] [ ]
2. List of reasons why I engaged vices:

For pleasure only [ ] I felt inferior [ ]
For curiosity [ ] I liked and enjoyed it [ ]
For experience only [ ] My parents tolerated of using it [ ]
I am distressed [ ] I want to destroy myself [ ]
Thank you…………….
QUESTIONNAIRE FOR THE RESPONDENTS
(For the Teachers)
Part I. Profile of Respondents
Name: ______________________________________________(Optional)
Part II. Classroom Behavior
Please check the appropriate box that corresponds to your answer using the
following rating scale.
3.26 – 4.00 VS Very Serious/Very Much influenced on
classroom behavior, significantly disrupting
the learning environment and hindering the
academic performance of the students.
2.51 – 3.25 MS Moderately Serious/Much influenced on
classroom behavior but do not significantly
disrupt the learning environment.
1.76 – 2.50 LS Least Serious/Least influenced on classroom
behavior that may not be noticeable or
significant.
1.00 – 1.75 NS Not Serious/Not influenced on the classroom
behavior of the students.
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
A. Withdrawn Behavior 4 3 2 1
1. Timidity
2. Blank Stares
3. Anxiety
4. Absenteeism
5. Introvert Behavior
6. Non-cooperativism
7. Non-participation in class discussion
8. Daydreaming
B. Disruptive Behavior
1. Giggling even if classes are going on.
2. Talking with seatmates.
3. Making unnecessary noise.
4. Refusing to follow instruction.
5. Going in and out of the classroom without permission.
6. Asking non-sense questions.
7. Cracking jokes while classes are going on.
8. Teasing classmates.
C. Violent and/ and Improper Behavior
1. Head banging
2. Kicking
3. Biting
4. Punching
5. Smashing equipment
6. Bullying
7. Stealing
8. Whistling
Part III. Attitude Towards School Work
Please check the appropriate box that corresponds to your answer using the
following rating scale.
3.26 – 4.00 VS Very Serious/Very Much Affected on their
attitude towards school work and is severely
impacting their academic performance.
2.51 – 3.25 MS Moderately Serious/Much Affected on their
attitude towards school work, but it is not
enough to significantly impact their overall
academic performance.
1.76 – 2.50 LS Least Serious/Least Affected on their attitude
towards school work, but it is not significant.
1.00 – 1.75 NS Not Serious/Not Affected on their attitude
towards school work.
= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
Attitude Towards School Work 4 3 2 1
1. Assignments and other home work.
2. School Beautification.
3. Language Campaign.
4. Brigada Escuela.
5. Sports Competition.
6. Mathematical Olympiad.
7. Gulayan sa Paaralan.
8. Tree Planting.
9. Clean and Green Program.
10. Homeroom Organization.
Thank you…………

Questionnaire For The Student On Vices

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QUESTIONNAIRE FOR THE STUDENTS

Sex: [ ] Male [ ] Female

Rating Scale Description/Implication

Statement Always Often Sometimes Never

2. List of reasons why I engaged vices:

Part I. Profile of Respondents

Part II. Classroom Behavior

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