HW5: Survey Form

 Diversity Among Filipino Families 

and Its Effects on Children

Please take a few minutes to fill out this survey and share your ideas. Your input will help the researcher to complete her research project. Your involvement in the study is voluntary, and your responses will be completely anonymous. You do not have to answer any question you would rather not answer. There are no consequences if you decide not to complete the survey and you can stop at any time.

Name: _(Optional)_

Gender: 

      Male
      Female

Age: ____________

Year Level: ______________

Are your parents together?
      Yes
      No
      Neither or N/A

 Do you live with...?
      Mother

      Father

      Both Mother and Father

      Neither Father nor Mother

      Others: ___________

Who is/are at home when you come home from school everyday?
     __________________________________________

What are your average grades in school? 

      0-55

      56-60

      61-65

      66-70
      71-75

      76-80
      81-85
      86-90
      91-95
      95-100

What are your vices? (Please select all that apply)
      None
      Cigarette smoking
      Drinking alcoholic beverages
      Others: _(Please specify)_

Thank you for taking the time to fill out this survey! :)