Sample Survey Questionnaire

SURVEY QUESTIONNAIRE ON THE SELF-LEARNING
MODULE DIMENSIONS
I. PERSONAL PROFILE: Please provide the following information either by
filling in the date or by putting a check that corresponds to your response.
Name: ___________________________________________________
Gender: ____Male ____Female Grade Level: ___________
Track: ______________________ Strand: ______________________
II. I am Paulino P. Tado, currently conducting a study entitled, “Influence of

Self-learning Module Dimensions and Parental Involvement on the Learning
Outcome of Students in Mathematics”. The data gathered from this
questionnaire are of great help to finish and fulfill this academic endeavor.
Hereunder are items which call for your honest assessment the level of
self-learning module dimension. Indicate a check mark (√) on the box placed at
the end of each item that would suit your perception based on your self-
assessment.
Rest assured that your responses will be treated with utmost
confidentiality and will be utilized solely for the needed data of the researcher’s
study, so please do not leave any item unanswered.
The following codes will help you in giving your rating.
Rating Scale Level Description
5 Very High This means that the item embodied is very

much observed.
4 High This means that the item embodied is
much observed.
3 Moderate This means that the item embodied is
fairly observed.
2 Low This means that the item embodied is less
observed.
1 Very Low This means that the item embodied is not
observed.
No. Indicators Rating
A. Content 5 4 3 2 1
1. The topics are clear and easy to understand.
2. The contents are appropriate to my grade level.
3. The topics are relevant to my daily activities.
4. The directions or instructions in the module are

easy to comprehend.
5. The examples are easy to understand.

B. Language 5 4 3 2 1
6. The words used are easy to understand.
7. The language used helped me to learn easily the

topics.
8. The terminologies used are familiar to me.
9. The sentences are easy to understand.
10. The language promotes good values towards my

interest to learn.
C. Presentation 5 4 3 2 1
11. The pictures and drawings are both familiar to

me.
12. The pictures and drawing matched the topics in

the module.
13. The presentation of contents catching my interest

to learn.
14. The font sizes are readable.
15. The pictures and drawings are easy to view.
D. Assessment 5 4 3 2 1
16. The assessment requirements and marking

criteria were clear.
17. The questions are easy to understand.
18. The questions matched the content of the topic.
19. The key answers for the assessment are clear and
easy to understand.
20. The module prepared me well for the assessment

tasks.
Source: Adapted from the Developed Module Questionnaire of Vergara (2017).

Survey Questionnaire on the Parental Involvement
I. PERSONAL PROFILE: Please provide the following information either by

filling in the date or by putting a check that corresponds to your response.
Name: ___________________________________________________
Gender: ____Male ____Female Grade Level: ___________
Track: ______________________ Strand: ______________________
II. I am Paulino P. Tado, currently conducting a study entitled: “Influence of Self-

learning Module Dimensions and Parental Involvement on the Learning
Outcome of Students in Mathematics”. The data gathered from this
questionnaire are of great help to finish and fulfill this academic endeavor.
Hereunder are items which call for your honest assessment on the level
of emotional competence. Kindly put a check (✓) on the box at the end of each
item that would suit your perception based on your self-assessment.
All of the answers you provide will be treated with utmost confidentiality
and will be utilized solely for the needed data of the researcher’s study, so
please don’t leave any item unanswered.
Based on your experience and observation at how well does the following
attitude, behaviors, thoughts, and feelings describe your parents’ involvement
in your school? The following codes will help you in giving your rating.
Rating Level Description

Always This means that the involvement of parents
5
is observed at all time.
Often This means that the involvement of parents
4
is observed most of the time.
Sometimes This means that the involvement of parents
3
is observed occasionally.
Seldom This means that the involvement of parents
2
is observed in few instances.
Never This means that the involvement of parents
1
is not observed in any instances.
No. Indicators Rating
A. Parenting 5 4 3 2 1
1. My parents frequently explain difficult ideas to me

when I don’t understand.
2. My parents provided dictionaries, Encyclopedia,

and other books in our house that help me in my
study.
3. My parents discuss the importance of good

education with me.
4. My parents encourage me to prioritize my class.
5. My parents supervised me when I watch

television/ playing computer games.
B. Communicating 5 4 3 2 1
6. My parents ask clarifications about my grades

during report card distribution day.
7. If I misbehaved at school, my parents would

know about it soon afterward.
8. May parents take the initiative to contact my

homeroom teacher.
9. My parents contact my subject teacher

pertaining to my academic progress.
10. My parents always know how well I am doing in

school.
C. Volunteering 5 4 3 2 1
11. My parents volunteer to facilitate in homeroom

class activities.
12. My parents volunteer to take part in maintaining

school facilities.
13. My parents volunteer in coordinating school

field trips or out-of-school activities.
14. My parents volunteer to take part in the school-

initiated programs like brigade eskwela and
others.
15. My parents volunteer to take part in school PTA

meetings
D. Learning at Home 5 4 3 2 1
16 My parents participate in learning activities with

me such as playing educational games.
17. My parents ensure that nobody disturbs me during

my studies.
18. My parents talk to me about my activities and

what I learned in school.
19. My parents monitor my habit of using gadgets such
as cell-phone, computers, and television.
20. My parents help me prepare for test and

examination at school.
21. My parents identify a regular time and place in our

home to accomplish homework.
E. Decision Making 5 4 3 2 1
22. My parents speak out opinions regarding the

school related activities and concerns.
23. My parents make suggestions to my teachers

about how to help me learn.
24. My parents take part in making decision about

homeroom project in school.
25. My parents provide suggestions on how the

distribution and retrieval of modules be done.
26. My parents participate and cast their votes

during the election of PTA officers in school.
F. Collaborating with the community 5 4 3 2 1
27. My parents meet barangay officials to help

school projects accomplished.
28. My parents talk with other parents frequently about

educational issues.
29. My parents work in partnership with the

teachers in finding ways to improve students’
academic success.
30. My parents cooperate together with PTA

officials in addressing school related
misbehavior of students.
31. My parents join forces with the school

stakeholders in responding to the new normal
set up education brought by COVID 19
pandemic.
Source: Adapted Parental Involvement Survey of Students (PISS) of Sheldon
& Epstein (2007).

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SURVEY QUESTIONNAIRE ON THE SELF-LEARNING

II. I am Paulino P. Tado, currently conducting a study entitled, “Influence of

Rating Scale Level Description

5 Very High This means that the item embodied is very

No. Indicators Rating

1. The topics are clear and easy to understand.

2. The contents are appropriate to my grade level.

3. The topics are relevant to my daily activities.

4. The directions or instructions in the module are

5. The examples are easy to understand.

6. The words used are easy to understand.

7. The language used helped me to learn easily the

8. The terminologies used are familiar to me.

9. The sentences are easy to understand.

10. The language promotes good values towards my

11. The pictures and drawings are both familiar to

12. The pictures and drawing matched the topics in

13. The presentation of contents catching my interest

14. The font sizes are readable.

15. The pictures and drawings are easy to view.

16. The assessment requirements and marking

17. The questions are easy to understand.

18. The questions matched the content of the topic.

20. The module prepared me well for the assessment

Source: Adapted from the Developed Module Questionnaire of Vergara (2017).

I. PERSONAL PROFILE: Please provide the following information either by

II. I am Paulino P. Tado, currently conducting a study entitled: “Influence of Self-

Rating Level Description

No. Indicators Rating

1. My parents frequently explain difficult ideas to me

2. My parents provided dictionaries, Encyclopedia,

3. My parents discuss the importance of good

5. My parents supervised me when I watch

6. My parents ask clarifications about my grades

7. If I misbehaved at school, my parents would

8. May parents take the initiative to contact my

9. My parents contact my subject teacher

10. My parents always know how well I am doing in

11. My parents volunteer to facilitate in homeroom

12. My parents volunteer to take part in maintaining

13. My parents volunteer in coordinating school

14. My parents volunteer to take part in the school-

15. My parents volunteer to take part in school PTA

16 My parents participate in learning activities with

17. My parents ensure that nobody disturbs me during

18. My parents talk to me about my activities and

20. My parents help me prepare for test and

21. My parents identify a regular time and place in our

22. My parents speak out opinions regarding the

23. My parents make suggestions to my teachers

24. My parents take part in making decision about

25. My parents provide suggestions on how the

26. My parents participate and cast their votes

F. Collaborating with the community 5 4 3 2 1

27. My parents meet barangay officials to help

28. My parents talk with other parents frequently about

29. My parents work in partnership with the

30. My parents cooperate together with PTA

31. My parents join forces with the school