SURVEY QUESTIONNAIRE FOR COMMUNITY ACTION
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Dear Student,
This survey intends to determine your level of understanding on the community
initiatives that you would like to benchmark, issues that you would like to address, and
the opportunities you would like to take in conducting community action plan.
In view of this, your utmost honesty, cooperation, and participation by answering
all the items the needed information in this questionnaire. Rest assured that your
answers will be treated confidentially and will be used solely for the creation of your
implementation plan of your identified community action.
Your cooperation will be highly appreciated.
Truly yours,
TEACHER
Part I. Student's Profile
Direction: Please answer correctly and honestly the following information by filling the
blank spaces or checking the correct box of your response.
Name :
Grade Level and Section:
Age: yrs. old
Sex: Male
Female
Part II. Community Initiatives Available
Direction: This evaluation is to appraise the community initiatives present being done
in your respective communities. Select your answer by checking the box.
A. Short-term Community Projects
Medical Mission
Dental Mission
Tree Planting
Sports / Game Festivals
Feeding Program
Family Recreational Activities
Tutoring Street / Underprivileged Children
1
B. Long-term Community Projects
Community Livelihood Projects
Building Cooperative in the Community
Continuous Training on the Disaster Preparedness and Management
Continuous Training on Waste Management
Lobbying for Community Relocation Site
Building Facilities in the Community (E.g. Day Care Center)
Community Gardening
Campaign to Raise Funds
Part III. Issues Needed to Consider in Conducting Community Action
Direction: This evaluation is to appraise the issues in the community that you deemed
important to consider in conducting community action plan in your respective
communities. Check your answer from the following scales:
Scale Descriptive Equivalent Interpretation
4 Strongly Agree Highly Encountered
3 Agree Encountered
2 Disagree Less Encountered
1 Strongly Disagree Not Encountered
Items 4 3 2 1
1. Adolescent pregnancy
2. Access to clean drinking water
3. Child abuse and neglect
4. Crime
5. Domestic violence
6. Drug use
7. Environmental contamination
8. Ethnic conflict
9. Health disparities
10. Poverty / Hunger
11. Inadequate emergency services
12. Bullying
13. Bystanders
14. Teenage smoking
15. Gang / Fraternity / Sorority
16. Unemployment
17. Poor waste management
18. Pollution
19. Gambling
20. Alcoholism
2
Part IV. Opportunities Contributory in Conducting Community Action
Direction: This evaluation is to appraise the opportunities that you are willing to
consider to realize your community action plan on your prospective
community initiative in your respective communities. Check your answer
from the following scales:
Scale Descriptive Equivalent Interpretation
4 Strongly Agree Highly Beneficial
3 Agree Beneficial
2 Disagree Less Beneficial
1 Strongly Disagree Not Beneficial
Items 4 3 2 1
1. Benchmark the best practices of other communities
2. Outsource information form project implementers the problems
encountered and the applicable solutions to them.
3. Outsource funds from NGOs and private individuals
4. Community survey (feedback from the officials and residents)
5. Information campaign / dissemination using multimedia (either
print, broadcast, or social media)
6. Tie up with other organizations / institutions to provide
community projects
7. Recruiting / scouting of volunteers for the realization of the
project
