QUESTIONNAIRE

LEVEL OF PRACTICE ON HEALTH PROTOCOLS IMPLEMENTATION IN

THE MUNICIPALITY OF BILIRAN

Dear Respondent,

Please indicate in the space provided your answers to the following question
by ticking (✓) where applicable. Please note that your personal information
and other details provided by you will kept confidential.

SECTION A: PERSONAL DATA COLLECTION

Direction. Please indicate in the space provided your answers to the

following question by ticking (✓) where applicable.

Name: ________________________________________
Address: ______________________________________
1. Gender:

Male ( )

Female ( )

2. Age:

Below 18 ( )

18-30 ( )

31-60 ( )

Above 61 ( )

3. Educational Attainment:

High School ( )

High School Graduate ( )

College ( )
 College Graduate ( )

Academic Degree Holder ( )

4. Marital Status;

Single ( )

Married ( )

Divorced ( )

Widowed ( )

5. Economic Status:

Stable ( )

Unstable ( )

SECTION B. RESEARCH QUESTIONNAIRE

Direction. The following questionnaire are the health protocols implemented

in the Municipality of Biliran. Please put a check mark in the relevant column.

Always Frequentl Sometimes Rarely Never

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

FACEMASK

1.I wear facemask when going

into public places.

2. I wash my hands before and

after touching the face mask.

3. I touch only the bands or ties

when putting on and taking off
my face mask.
4. I make sure the face mask fits
to cover my nose, mouth, and
chin.

5. I wash reusable masks after

each use.
6. I don’t remove my face mask
while around in public.
7. I don’t share my mask with
my family members or friends.
8. When I used surgical mask, I
immediately disposed of it after I
used it.

SOCIAL DISTANCING

Always Frequentl Sometimes Rarely Never

Indicators (5) y (3) (2) (1)
(4)
9. I’m doing the 1 meter
distance from each other.
10. To prevent the infection of
COVID-19, I avoid going to
crowded places and avoid
taking public transportation.
11. I don’t engage in
unnecessary physical contact
with others.
12. I avoid crowded gatherings.

13. Handshaking and other

physical contact are
discouraged for me.
14. I avoid going to the
gathering in groups, including at
a friend’s house, parks,
restaurants, shops or any other
public place.
15. I go to the store at times
when there are likely to be fewer
people shopping.

BORDERS AND PUBLIC ESTABLISHMENTS REQUIREMENTS

Always Frequentl Sometimes Rarely Never

Indicators (5) y (3) (2) (1)
(4)
16. I present my QR code when
going outside and inside of the
border.
17. I present my vaccination
card when going outside and
inside of the border.
18. I present my QR code when
going into the store.
19. I present my QR code when
going into the mall.
20. I present my vaccination
card when going into the mall.

PROPER ETIQUETTE

Always Frequentl Sometimes Rarely Never

Indicators (5) y (3) (2) (1)
(4)
21. I maintain clean environment
to prevent COVID-19.
22. I cover my mouth and nose
while coughing or sneezing.
23. I practice proper hygiene.

24. I wash my hands regularly.

25. I practice proper hygiene.

26. I wash my hands regularly.

27. I keep my unwashed hands

away from my face.
28. I avoid touching my eyes,
nose, or mouth with my
unwashed hands.

ISOLATION

Always Frequentl Sometimes Rarely Never

Indicators (5) y (3) (2) (1)
(4)
29. I stay at home if I have a
cough or fever in the last 72
hours.
30. I self-isolate when
developing symptoms or test
positive for COVID-19 until I
recover.

HEALTH CONCERN

Always Frequentl Sometimes Rarely Never

Indicators (5) y (3) (2) (1)
 (4)
31. I cooperate in checking my
temperature in public places.
32. I seek medical attention
immediately if I have fever,
cough, and difficulty in
breathing.
33. I avoid sharing personal
stuffs to prevent the infection of
COVID 19.

Other (please specify): ____________________________________

Approved by:

HILDA P. ALBA
Research Adviser

JEROME B. PALCONIT
Research Teacher

Panelist:

RIZA P. PALCONIT

DINAH N. PACATANG

ANNIE LUZ G. YAPAN

ROSE D. ARCOSIBA