Appendix A

Survey Questionnaire
(All information given will be dealt with utmost confidentiality)

Instruction: Please fill-out this form honestly. Do not leave any item blank.
I. Personal Information:
Age: _________ Sex: ___________________Grade Level: ___________
No. of children in the family:_________

Birth order (Pls. check the blank):

______Eldest child _______Only Child
______Middle child _______Others (pls. specify)
______Youngest Child
Living with/at:
______Parents _______Siblings
______Grandparents _______Others (pls. specify)
______Relatives
______Boarding House
Monthly Family Income:
______5,000 and below
______5,001 – 10,000
______10,001- 15,000
______15,001 and above
Type of student:
______Full-time student
______Working student/self-supporting
______Kalinas/Canadian/4P’s Beneficiaries/with scholarship
grants

Reasons of being held back to the same Grade level:

______Chronic Absences ______No Parental Support

______Lack of Interest ______Family Problem
______Difficulty in understanding the subject ______Teacher Factor
______Involving to Barkada ______Health Problem
______Cutting Classes ______Financial Problem
______Vices/Computer Addiction ______Others (pls.specify)
II. For every item, kindly check the box under the frequency that best describes you.
Socio-Emotional Challenges At All Often Sometimes Seldom Never
Times
Self-esteem
1. On the whole, I am satisfied
with myself
2. I have much to be proud of
3. I am confident in facing
other people
4. I feel that I’m a person of
worth, at least on an equal
plane with others
5. I can accept criticisms well
6. I know what is expected of
me
7. I have a positive outlook in
life
8. I have self-respect.
9. I don’t need others’ approval
to feel good.
10. I am accepted what I am
Cognitive Competence At All Often Sometimes Seldom Never
Times
1. I am motivated to learn
2. I have a good understanding
of the things I learn at school
3. I am doing well with my
academics
4. I know my goals and I am
capable of achieving it
5. I can accept criticism without
being put down
6. I can meet the deadlines of
my school requirements
7. I am responsible for every
decision I make in school
8. I don’t get affected if I fail on
a quiz or exam because I
know I can do better next
time
9. My efforts will result into
success of my studies
10. I am aware on how to handle
my school problems
Social Skills At All Often Sometimes Seldom Never
Times
1. I make friends easily
2. I have someone whom I can
share how I feel.
3. I can easily seek for advice
from my friends about my
 problems in school
4. I am participative on any
kind of school work
5. I can get along with different
people
6. I can rely on my friends who
have had similar experience
like mine
7. I can deal any situation in my
environment
8. I am easily understood by
others
9. I am at ease when I am
around with people
10. I spend quality time talking
with my new friends

Coping At All Often Sometimes Seldom Never

Times
Self-esteem
1. I am contented with my own
achievement
2. I am proud of my own
achievement
3. I am confident meeting new
classmates
4. I take the courage to face my
own problems.
5. I take feedbacks
constructively
6. I do not compare myself to
my classmates
7. I take a positive attitude
toward my own problems
8. I maintain self-respect
9. I can accomplish what I am
capable of
10. I don’t mind what other
people say against me
Cognitive Competence At All Often Sometimes Seldom Never
Times
1. I do my best in
accomplishing my school
work
2. I exert efforts to succeed in
my studies
3. I study my lessons well in
order to pass my subjects
4. I monitor my progress in
achieving my goals
5. I modify strategies that are
 unsuccessful
6. I make sure that I can finish
my school requirements
ahead of time
7. No matter how bad it gets, I
know I can handle it
8. I see my problems as a
challenge and I don’t let it
bother me
9. I tell myself that I can’t let
the struggles stand in the
way of what I have to do
10. When I think about my
problem in school, I can
easily think of a solution
Social Skills At All Often Sometimes Seldom Never
Times
1. I introduce myself to new
people without being told
2. I share my feelings to my
close friends.
3. I approach my friends for
some advices regarding my
problems in school
4. I volunteer to help my
classmates with the
classroom task
5. I persevere to work with my
classmates until the task is
finished
6. I seek help to my friends who
have had similar experience
on how they overcome their
struggles
7. I respond appropriately to
the people in my new
environment
8. I compromises in conflict
situations by changing own
ideas to reach agreement
9. I establish friendship with my
new classmates
10. I initiate conversations with
my new classmates

Thank You!