SAMPLE QUESTIONNAIRE

Name (Optional) _________________________________________________

Age _______ Gender ______ Civil Status ______

Direction: Please put a check mark to the blank provided corresponds to any number
written above each item to best express your opinion by using the following code below:
5 – Strongly Agree
4 – Agree
3 – Moderately Agree
2 – Disagree
1 – Strongly Disagree
II. Determine the level of student’s awareness of the causes of bullying among Senior
High School students of Naval National High School.
CAUSES 5 4 3 2 1

1. Lack of involvement in child’s interests,

activities, and daily life.
2. Lack of supervision

3. Overly permissive, lack of limits

4. Harsh physical discipline

5. Unsupervised break times

6. Unsupervised student areas such as

lunchrooms, bathrooms, hallways,
locker rooms, playgrounds
7. Emotionlessness towards bullying on
the part of administrators
8. Idealize Violence
III. Determine the level of perception of Senior High School on the effects of bullying.
5 – Strongly Aware
4 – Aware
3 – Moderately Aware
2 – Unaware
1 – Strongly Unaware
Effects 5 4 3 2 1
a. Loss of interest in school and extra-
curricular activities
b. Frequent complaints of illness to avoid
attending school
c. Sudden decrease in academic
performance
d. Seems afraid in going to school, riding
the bus, walking to school, or taking part
In organized activities with peers
e. Anxiety or low self-esteem