Name: ________________________________ Date: ______

Age: _____ Yea Level: _____ Sex: _____ Status: _____

Instructions: Supply the needed information by putting a check (mark on the space provided.

Encircle.

Family Income

What is your expected family income per month?

a) 2,500-5,000
b) 5,000-8,000
c) 8,000-10,000
d) Others specify _______
Parents’ educational attainment

What is your parents educational attainment?

a) Elementary under graduate

b) Elementary graduate
c) High school under graduate
d) High school graduate
e) Vocational
f) College under graduate
g) College graduate
h) Masteral
Mass Media Exposure

Numbers of hours using technological devices

a) 2-3 hours
b) 3-6 hours
c) 6 hours and above
What technological devices you use for online learning.

a) Cellphone
b) Laptop
c) Netbook
d) Tablet
e) Computer

1
What mobile application you are using for online learning.

a) Google meet app

b) Google classroom
c) Zoom cloud
d) Facebook messenger
e) Others specify _______

Self-learning

Statements/Question Strongly Agree Agree Slightly Agree Disagree

s
1. I set targets to
achieve for
assignments or
activities
2. I reflect on what I
have learned during
the lesson.
3. I find time to study
the learning materials
or resources in the
course.
4. I spend too much
time researching
information for my
assignments
5. I know how to pick
up important
information during
sessions.
6. I persist in finishing
and complete task as
quickly as possible.
7. I do not submit my
assignment on time.
8. I can follow the
pace of online.
9. I do not understand
the lesson during
seasons.
10. After the
discussion, there are
some questions in my

2
mind.

Engaging Learning

Statements/Question Always Very Often Seldom Very Never

s Seldom
1. I plan what I need
to learn.
2. I do well on my
assignments.
3. I follow my study
schedule.
4. I joined meeting on
time.
5. I learn from my
instructor during
discussions.
6. I feel motivated
whenever I am
studying.
7. I do not understand
my instructor when
the connection
interrupted.
8. I cannot focus
during sessions.
9. I feel discourage
when I cannot
response to discussion.
10. I feel distracted on
learning because of
social media such
Facebook, Instagram
and online games.

Effective Communication

Statements/Questions Very Useful Slightly Lest Useful Useless

Useful Useful
1. I do listen when
someone is presenting
or asking some

3
questions.
2. I am able to
response during oral
recitation.
3. I do well understand
the lesson presented.
4. I respect others
points of view through
engagement and
interest.
5. I can explain and
clarify thoughts and
ideas.
6. I possess sharp
observe skills to gain
more knowledge and
information.
7. I am able to
understand and
interpret the lesson
well.
8. It builds my
confidence in
delivering my ideas.
9. I can accept an
immediate feedback
from my instructor.
10. I can share my
ideas to influence
other from within.