1.
2.
3.
4.
5.
6.
7.
Name (Surname, First name, MI.)
School Attended
Age
SEX
Grade Level
Address
Number of Family Members
0-5 y.o
6-10 y.o
11-15 y.o
16-20 y.o
21-30 y.o
30 above
8. Students
9. What devices are available at home that the learner can use for learning? Check all that applies.
Cable tv
Non-cable tv
Basic cellphone
Smartphone
Tablet
Radio
Desktop or computer
Laptop
None
Others: ______
10. Who among the household members can provide you instructional support to distance
learning? Choose all that applies.
Parents/guardians
Elder sibling
Grandparents
Extended members of the family
Others (tutor, house helper
None
Able to do independent learning
11. How do you connect to the internet? Choose all that applies.
Own mobile data
Own broadband internet (DSL, wireless fiber, satellite)
Computer shop
Other place outside home with internet connection
Library/barangay/municipal hall, neighbor, relatives)
None
12. What are the challenges that may affect your child’s learning process through distance
education? Choose all that applies.
Lack of available gadgets/equipment
Insufficient load/data allowance
Unstable mobile/internet connection
Existing health conditions
Difficulty in independent learning
Conflict with other activities (i.e., house chores)
High electrical consumption
Distraction (i.e., social media, noise from community/neighbor
Others:
13. Factors Affect your Learning:
1. Students Demographic profile (Learning distance from the school to the home of learners)
2. Lack of Parental/ Guardian Support
3. Lack of Financial Support
4. Degree of Difficulty
5. Teacher Support
6. Study Environment
7. Language use in the learning modules or Learning Activity Sheets
Dear Learners’:
Thank you for responding and completing this survey. Please be honest in your views and base your
answer on your personal observations of modular distance learning. You may or may not indicate your
name in the respondent’s profile for confidentiality of your identity.
In accordance of RA 10173 or Data Privacy Act of 2012, all personal and/or sensitive information solicited
and disclosed from this questionnaire shall be only used for the study alone. Rest assured that your
responses in this instrument will be kept confidential. Thank you for taking time to complete this
questionnaire.
Respectfully yours,
SHIELO B. CABAHUG
Student/Researcher/Teacher