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Pamantasan ng Cabuyao

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COLLEGE OF NURSING 101

Questionnaire

PALLIATIVE CARE: AN EMERGING ROLE

Name (Pangalan, opsyonal): ________________________________________

PART I. DEMOGRAPHIC PROFILE OF THE RESPONDENTS

1. Age (Edad): ( )20-30 ( )31-40 ( )41-50

( )51-59 ( )60 Above (Pataas)

2. Gender (Kasarian): ( )Male (Lalaki) ( )Female (Babae)

3. Educational attainment: ( )Elementary ( )High School ( )College

4. Family Monthly Income (Buwanang kinikita ng pamilya):

( )5,000 ( )5,000-10,000 ( )10,000 above (pataas)

PART II. LEVEL OF AWARENESS ABOUT PALLIATIVE CARE

INSTRUCTIONS: Please check the best answer that corresponds to each


question given. All responses will be kept confidential and anonymous.

Scale Interpretation
5 Excellent
4 Satisfactory
3 Good
2 Fair
1 Poor
Pamantasan ng Cabuyao
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COLLEGE OF NURSING 102

A. LEVEL OF AWARENESS 5 4 3 2 1
1. Oxygen tank lent
2. Medications given
3. Spiritual support
4. Psychosocial support
5. Provided Nurse
6. Ambulance
7. Stretcher
8. Wheel chair
9. Therapy
10. Check up

B. INFORMATION 5 4 3 2 1
1. Have personally received or relative received Palliative
care

2. Friend discussed it

3. Relative discussed it

4. You work in Palliative Care

5. You work in a medical field

6. Radio

7. Television

8. Newspaper

9. Magazine

10. Other
Pamantasan ng Cabuyao
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COLLEGE OF NURSING 103

RECOMMENDATION AND SUGGESTION:

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