QUESTIONNAIRE

LEVEL OF PRACTICE ON HEALTH PROTOCOLS IMPLEMENTATION IN

THE MUNICIPALITY OF BILIRAN

Dear Respondent,
We would like to ask for your help to kindly accomplish the
questionnaire of our research “LEVEL OF PRACTICE ON HEALTH
PROTOCOLS IMPLEMENTATION IN THE MUNICIPALITY OF BILIRAN” by
answering heartily all items found in each category. Please do not leave blank
answer to the questions. Your answer will be kept confidential in accordance
with the ethics of research, and feel free to answer the questions.

PART I. PROFILE OF THE RESPONDENTS

Direction. These questions contain about your personal information. Please
answer it honestly.

Name (optional):_______________________________ Sex:____ Age:__

Address: ______________________________________________
Educational Attainment:
Civil Status:
Economic Status:
Stable
Unstable
PART II. LEVEL OF PRACTICE ON HEALTH PROTOCOLS
IMPLEMENTATION IN THE MUNICIPALITY OF BILIRAN
Directions. Using the 5 point scale shown below. Rate the following
questions by placing a check in the box. Please answer the question honestly.
Do not leave each item unanswered.
Scale;
5 = Always 4 = Frequently 3 = Sometimes 2 = Rarely 1 = Never

A. FACEMASK
Indicators (5) (4) (3) (2) (1)

1. I wear facemask when going into public places.

2. I wash my hands before and after touching the
face mask.
3. I make sure the face mask fits to cover my
nose, mouth, and chin.
4. I wash reusable masks after each use, while I
immediately dispose the surgical mask after I use
it.
5. I don’t share my mask with my family members
or friends.
Others, please specify;

B. SOCIAL DISTANCING
Indicators (5) (4) (3) (2) (1)

1. I practice the 1 meter distance from other

people.
2. To prevent the infection of COVID-19, I avoid
going to crowded places and avoid taking public
transportation.
3. Handshaking and other physical contact are
discouraged for me.
4. I avoid going to the gathering in groups,
including at a friend’s house, parks, restaurants,
shops or any other public place.
5. I go to the store at times when there are likely
to be fewer people shopping.
Others, please specify;
 C. BORDERS AND PUBLIC ESTABLISHMENTS REQUIREMENTS
Indicators (5) (4) (3) (2) (1)

1. I present my QR code when going outside and

inside of the border.
2. I present my vaccination card when going
outside and inside of the border.
3. I present my QR code when going into the mall.
4. I present my vaccination card when going into
the mall.
5. I cooperate in checking my temperature in
public places.
Others, please specify;

D. PROPER ETIQUETTE
Indicators (5) (4) (3) (2) (1)

1. I maintain a clean environment to prevent

COVID-19.
2. I cover my mouth and nose while coughing or
sneezing.
3. I practice proper hygiene.
4. I avoid touching my eyes, nose, or mouth with
my unwashed hands.
5. I avoid sharing personal stuffs to prevent the
infection of COVID 19.
Others, please specify;

E. QUARANTINE AND ISOLATION

Indicators (5) (4) (3) (2) (1)

1. I stay at home if I have a cough or fever in the

last 72 hours.
2. I self-isolate when developing symptoms or test
positive for COVID-19 until I recover.
3. I seek medical attention immediately if I have
fever, cough, and difficulty in breathing.
4. If I experience symptoms associated with
COVID-19, I refrain from going to public places.
5. I have come into close contact with someone
who has COVID-19, I immediately isolate myself.
Others, please specify;
Approved by:

HILDA P. ALBA JEROME B. PALCONIT

Research Adviser Research Teacher

Panelist:

RIZA P. PALCONIT

DINAH N. PACATANG

ANNIE LUZ G. YAPAN

ROSE D. ARCOSIBA