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Republic of the Philippines

JOSE RIZAL MEMORIAL STATE UNIVERSITY
The Premier University in Zamboanga del Norte
Main Campus, Dapitan City

SURVEY INSTRUMENT

Instruction: Please answer the questionnaire below by checking the box for

your responses. You can rest assured that your responses will be taken care of and will be

treated with utmost confidentiality.

Researcher

Part 1. Profile of the inmates in terms of:

A. AGE

18-25 years old ( )

26-35 years old ( )

36-45 years old ( )

46-55 years old ( )

56-65 years old ( )

66 Above ( )

B. GENDER

Male ( )

Female ( )

C. MARITAL STATUS

Married ( )

Single ( )

Widow ( )
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C. NO. OF CHILDREN (18-BELOW)

1-3 ( )

4-6 ( )

6-above ( )

D. CHILD CURRENT CAREGIVER

Other parent ( )

Grandparent ( )

Other relatives ( )

Foster home or agency ( )

Friends, others ( )

E.CRIMES COMMITTED

Murder ( )

Homicide ( )

Robbery ( )

Theft ( )

Other Please Specify: __________________________________

F. LENGTH OF INCARCERATION

1 year and Below ( )

2 to 4 years ( )

5 to 7 years ( )

8 years and Above ( )

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Part 2. Impact of Parental Imprisonment to the socio-cultural endeavor of their

children.

Instruction: Please rate your experiences to the given situation before and during

imprisonment of your parent. Please put a check mark ( ) on the box that corresponds

your response. You can rest assured that your responses will be taken care of and will be

treated with utmost confidentiality.

Researcher

5 Very Much Influencial

4 Much Influencial
3 Influencial
2 Less Influencial
1 Not Influencial

Before During
A. Family Imprisonment Imprisonment
5 4 3 2 1 5 4 3 2 1
1. I don’t want to be with my family.
2. I no longer listen to my elders/adults
3. I get mad when others associate me
with my parent in jail.
4. I prefer my friend’s company over my
family’s gathering.
5. I don’t want to see my incarcerated
parent.

Before During
C. School Imprisonment Imprisonment
5 4 3 2 1 5 4 3 2 1
1. I don’t participate in classroom
decisions.
2. I don’t participate in school contest and
activities.
3. I always got into fight with my
classmate.
4. I skip/stop attending classes.
5. I am ashamed to go to school.
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Before During
E. Community Imprisonment Imprisonment
5 4 3 2 1 5 4 3 2 1
1. I withdrawn myself from others.
2. I don’t meet/ play with my neighbors.
3. I no longer go to church.
4. I am uninterested with other’s well-
being
5. I don’t mind hurting someone or
something.