Preliminary Survey Questionnaire

Part 1. Demographic profile Instruction: Please provide the following with the appropriate information. Write the answer on the space provided. Any information given will be strictly confidential.

Name: ______________________________________________________ Age:__________ Gender:_______ College:_____________________ Birthdate:__________ Civil Status:_________ Year Level: _________

Part 2. Students perception towards smoking Instructions: For items with multiple choices, encircle the letter corresponding to your answer, otherwise mark check.

1. What are your average daily allowance? a. 50-100 b. 100-150 c. 150-200 d. 200 and above 2. Who lives with you most of the time? a. immediate member of the family b. with boardmates or roommates c. with relatives

d. with friends 3. During family gatherings do you discuss problems associated with smoking? ___yes ___no ___not sure

4. Who are the smokers among the immediate members of the family? (can choose more than one) ___father ___mother ___brother ___sister 5. During the past 7 days on how many days have people smoked in your presence? a. 0 b. 1-3 c. 4-6 d. 7 and above 6. Is there action taken against students who are caught smoking? ___yes ___no ___not sure 7. How many of your friends smoke? ___none ___few ___many

8. Do you think smokers have more friends than non-smokers? ___yes ___no ___not sure 9. do you think it is safe to smoke for only a year or two as long as you quit after? ___yes ___no ___not sure 10. Do you think the smoke from other peoples cigarette are harmful to you? ___yes ___no ___not sure 11. During this school year did you discuss in any of your classes the reasons why people your age smoke? ___yes ___no ___not sure 12. Once someone has started smoking, do you think it would be difficult to quit? ___yes ___no ___not sure

13. Do you have access to television or radio? ___yes ___no

14. Have you tried to smoke even once? ___yes ___no 15. Do you smoke? ___yes ___no