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_______________ Dear Participant, Greetings! We are currently undertaking a degree on Bachelor of Science in Nursing and a research proposal entitled Health Needs of Students Grants-in-Aid Program for Poverty Alleviation (SGP-PA) Grantees in a State University is to be submitted as a partial fulfillment of the course. This is a letter to invite you to partake in this study. The study will involve you completing a two part questionnaire which will take approximately 20-30 minutes for you to answer. We would like to ask you to answer the questions truthfully and independently. Confidentiality and anonymity will be fully assured, as your name is not required and only the research team will have access to the results. It will not affect you or your scholarship in anyway, should you not take part in this study. By completing this questionnaire, it is understood that you are consenting to participate in this study. Your participation would be greatly appreciated. Thank you for taking the time to read this letter. Yours sincerely, NIO VICO C. AMIDO KARIZZA ZOETTE ANN F. ALCARDE MA. RISA JOY A. AURO ELLAINE S. BALENTOS PHOEBE P. BERNADAS CHERRY ANN L. BORBON NIYLYN C. CALICARAN

_________________________________________ Printed Name of Participant and Signature

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RESEARCH INSTRUMENT I. PERSONAL DATA _______________________ Age: ______

Date of Birth: II.

Instruction: Please check () the following spaces provided for your corresponding answer. A. Sex: ( ) Male ( ) Female B. Civil Status: ( ) Single ( ) Married ( ) Separated C. Course: ( ) Bachelor of Science in Information Technology ( ) Bachelor in Special Education D. Religion: ( ) Roman Catholic ( ) Baptist ( ) Seventh-day Adventist ( ) Jehovahs Witnesses Others, pls. specify: __________________ E. Province: ( ) Antique ( ) Aklan ( ) Negros Occidental ( ) Guimaras

Your responses will provide important information to identify health needs of the SGP-PA Grantees to support your health and well-being. The information you share will be kept PRIVATE between you, the researchers and the institutions which established and developed the SGP-PA program unless information is needed to protect you from immediate danger.

Choose and write a check () mark in the box that best describes your answer.
ALWAYS is meant for doing things at all times OFTEN is meant for doing things many times SELDOM is meant for doing things in a few instances NEVER is meant for things not done at all

1. 2. 3. 4.

ITEMS I skip eating breakfast I skip eating lunch I skip eating dinner If I missed a meal, the reasons would be the following: a. Not hungry / have no appetite. b. I overslept. c. I do not have enough time to eat. d. I am too busy with planned activities. e. I want to lose weight. f. I forgot my money. g. There is nothing I like to eat. h. I dont have enough money.



Seldom 1.44 1.05 1.13 1.05 1.13 1.17



0.48 0.57 1.1 1.36

Choose and check () the box that best describes your answer. 5. How many hours do you usually sleep in a day? -3- 2.73 7 8 hours 1 4 hours 5 6 hours 9 hours or more Page 2 of 8

6. How often do you have trouble with sleeping?2.15 -2More than twice a week Once a week Twice a week 7. How often do you take a bath? Every other day Never Daily

Twice a day Weekly 8. How often do you do handwashing? Before and after eating Occasionally Every after each work Before sleeping 9. What are your usual handwashing practices? With Water Only With Soap and brush With Soap Others, pls. Specify 10. How often do you brush your teeth? 2x a day More than 3x a day 3x a day Once a day

11. Some common activities are listed below. How often do you take part in these activities? Choose the box that most closely describes your participation level. Always means that it is done all the time Often means that it is done many times Sometimes means that it is done at times or now and then Rarely means that it is done in few instances Never means that it is not done at all ITEMS a. Engage in sports and outdoor activities. b. Work out or jog for at least 15 minutes c. Go to watch events such as basketball games. d. Go to social dances such as Disco or hataw e. Watch TV or movies with friends and family f. Watch TV or movies alone g. Listen to radio/music with friends and family h. Listen to radio/music alone i. Hang out with family or friends, talk to friends on the phone The following questions deal with things people do that protect their health. Choose and put a check () on the box that best describes your answer. Always 12. During the past 6 months, how often have you Page 3 of 8 Often Sometimes Rarely Never Always Often Sometimes Rarely Never

experienced the following: a. Headache b. Stomachache c. Backache d. Feeling Low (depressed, sad) e. In a bad mood (irritable, cranky) f. Feeling Nervous g. Cough h. Not Feeling Well i. Others:__________ Always 13. During the past 6 months, how often were you: a. Hungry at school that you cannot concentrate on your school work. b. So stressed out or worried at school that you could not concentrate on your school work. c. So tired at school that you cannot concentrate on your school work. d. So physically or mentally tired at the end of the school day that you could not enjoy your time away from school 14. Have you smoked cigarettes? No Yes Often

1.76 1.44 1.41 1.97 1.85 1.44 1.33 1.52

Sometimes Rarely Never





15. If you answered yes, how often do you smoke? 4-6 times a week Once a week 2-3 times a week Everyday

16. How many cigarettes do you usually smoke in a day? 1 5 sticks 6 10 sticks 11 15 sticks 17. Do you drink alcoholic beverages? Yes No 18. If yes, what beverage do you usually drink? Beer Brandy Rum Wine Page 4 of 8 15 or more sticks

Gin Whisky 19. If yes, how often do you drink anything alcoholic? Everyday Every Week

Once a week Once a month 20. Which of the following beverage do usually take? Beer Rum Brandy Wine

a. For those who answered beer, how much do you usually consume in one drinking? 4 6 bottles 1 3 bottles 7 9 bottles 10 bottles or more

b. For those who answered rum, brandy, wine, whisky and gin how much do you usually consume in one drinking? 1 3 shots 4 6 shots 7 9 shots 21. Have you ever used prohibited drugs? Yes 22. If yes, what forms? Marijuana Cocaine 23. Do you engage in sex? Yes Inhalants Heroin No No 10 shots or more

24. If you answered yes, before your last sex, did you drink alcohol? No Yes 25. When you are worried or upset, are there people whom you can talk to? Yes No 26. When you are worried, upset, or under stress, how many people can you really count on to understand how you are feeling? AT HOME No One 1 person 2 or more AT SCHOOL No One 1 person 2 or more ELSEWHERE No One 1 person 2 or more

27. Which of the following statements best describes the family that you currently live with most of the time? A very close family A fairly close family A happy family An unhappy family

28. Please indicate how much you agree and disagree with each of the following sentences. Strongly Strongly Agree Uncertain Disagree Agree Disagree a. If I have problems 3.19 at school, my parent(s) / Page 5 of 8

guardian(s) are ready to help me b. If I have problems at school, my parent(s) / guardian(s) are willing to come to school to talk with teachers c. My parent(s) / 3.52 guardian(s) encourage me to do well at school 29. How do you feel about school? Best Better 30. Do you feel safe in school? Yes 31. Have you been under counseling? Yes a. If yes, to whom did you visit? School Official


Good Fair No



Guidance Counselor Friend 32-35 below are some questions about bullying. Bullying is when a person is teased repeatedly in a way he/she doesnt like. Bullying may also occur indirectly by causing a person to be socially isolated. 32. Have you ever been bullied in school? Yes No

33. If yes, how often have you been bullied in this school? Daily Once a week 34. Who usually bullies you? Friends Classmates Teachers Others, pls. specify _________ Hit, slapped or pushed you Took or stole personal items from you Spread rumors or lies about you Two times a week 3 or more

35. What were the means of bullying? Made fun of your physical looks Purposely left you out of activities or isolated you Threatened you

Made sexual jokes, comments or gestures to you 36. Since the start of school year 2013-2014, about how many days were you absent from school? None 1-2 weeks 1 week More than 2 weeks to 1 month 37. For which of the following reasons were you absent from school? I was sick or injured I was looking after someone at home I am sleepy in school I was having a hard time coming to school Page 6 of 8

Others, pls. specify _____________________________ 38. For the next set of questions, please take the box to indicate your answer.

Very Quite easy Easy

a. How do you find discussing your feelings with your friends? b. How do you find it to make new friends? c. How do you find it to tell a friend about your weaknesses and failures? d. How do you find it to tell a friend about your achievements and success? 2.55 2.63

Not very Easy

Quite Very Difficult Difficult

2.27 2.69

39. Where do you live? Family home Second Family Distant Relatives Friends

Others, pls. specify ____________ Immediate Relatives 40. In your opinion, how would you describe your health? Fair Very Good Good Excellent 41. Do you think your body is: Please check one response that best describes who you are? Very thin Fat Thin About the right size 42. Are you on a diet to lose weight? No, my weight is fine Yes If yes, why? ____________________________________________ 43. Are you trying to gain weight? No, my weight is fine Yes If yes, why? ____________________________________________ 44. Choose and write a check () mark in the box that best describes your answer.
Strongly Agree a. b. c. I have confidence in myself I am satisfied with myself I usually behave according to my beliefs Agree Uncertain 3.05 3.05 3.05 Disagree Strongly Disagree

Very fat

No, but I need to lose weight

No, but I need to gain weight

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d. e. f. g. h. i. j. k. l. m. n. o.

I often wish I were someone else I always have trouble making my own decisions My parent(s) understand me My parent(s) trust me I have a happy home life I have a lot of arguments with my parent(s) What my parents think of me is important I find it hard to make new friends I often have trouble expressing my feelings to others I have a large circle of friends I often have a hard time saying no to my friends I dont like crowded events

2.16 1.75

3.61 3.2 1.68 3.25 1.85 1.84 2.56 1.97 2.57

45. What would you like to do in the next year to improve or maintain your health? Check ALL the boxes that apply to you. Be more physically active Eat healthier food Quit smoking or smoke less Drink less coffee Drink less alcohol Lose weight Gain weight Change my home situation Get Medical Treatment Remove major cause of stress Learn to manage money better Learn to cope better with stress Learn to manage time better Learn to communicate better Learn to deal with relationships Deal/cope with bullying Deal/cope with violence Nothing

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