Part I

Direction: Complete the section by putting () on the space provided before the items if you feel that the
statement accurately describes you. If not, please specify.

Name (optional)________________________ Level & section: _____________________________

Sex: Male Female Age: _________

Civil status: Single Married Separated Divorced Widowed

Socioeconomic Status: What is your total combined family income for the past 12 months, before taxes,
from all sources, wages, public assistance/benefits, help from relatives, alimony, and so on? If you don’t
know your exact income, please estimate.

Poor Less than P9, 100

Low Low- income P9, 100- P18, 200
Lower middle P18, 200 – P36, 400
Middle- middle P36, 400 – P63, 700
Middle Upper- middle class P63, 700 – P109, 200

Upper class P109, 200 - 182, 000

Upper Rich ABOVE 182, 000

Year Level: First year Second year Third year Fourth year

Family Structure:

Nuclear Family (consist of two parents and their kids)

Extended Family (consist of lots of relatives that live together)
Single Parent Family (consist of one single parent who raise one or several children by
themselves)
Step Family (consist of a new husband or wife, along with their children from a prior
marriage or relationship, form this kind of family which. combines two separate families into
one)
Others (specify)
 Part II

Direction: For each statement in the survey, please indicate how much you agree or disagree with the
statement by putting a check in the box on the right side of each statement. There are no right and
wrong answers. Your answers will be kept strictly confidential and you will not be identified.

Scale 5- Strongly Agree (indicates that the characteristic is always manifested)

4- Agree (indicates that the characteristic is often manifested)
3- Neutral (indicates that the characteristic is sometimes manifested)
2- Disagree (indicates that the characteristic is rarely manifested)
1- Strongly Disagree (indicates that the characteristic is never manifested)

IIa. CRITICAL THINKING SKILLS

A. Knowledge: Identification and recall of 5 4 3 2 1

information strongly agree Neutral Disagree Strongly
agree disagree
1. I can detect the problems in a matter,
explain and define them.
2. By means of explanation regarding a
matter, I can predict the ideas
unexplained.
B. Comprehension: Organization and selection of facts and ideas.
3. I can understand pale in the matter and
obscurities from explanations regarding
the matter.
4. when I read a matter, I can understand
the main idea and intention of the
writer.
5. I can explain my thoughts regarding a
matter convincingly and logically.
6. When I encounter a matter, I can be
more elaborative thanks to my thoughts.
7. When I encounter a matter or an action,
my thoughts do not misguide me.
C. Application: use of facts, rules, and principles.
8. When I encounter a problem, I can solve
it and make deductions.
D. Analysis: Separating a whole into component parts.
9. While a matter is explained, I can
analyze it by thinking the datas
regarding that matter.
10. From the explanation regarding a
matter, I can find the contradiction
 between reason and result.
11. While a matter is explained, I can
concentrate on the matter together with
my thoughts.
12. When I encounter a matter, I can think
critically, reasoningly and analytically.
E. Synthesis: Combining ideas to form a new whole
13. By means of my thought regarding a
matter, I can improve hypothesis
regarding the matter.
14. By means of explanation regarding a
matter, I can establish striking
connections regarding the matter.
F. Evaluation: Developing opinions, judgement, or decisions
15. When I encounter a matter, I consider it
with disadvantage without thinking.
16. When I encounter a matter, I realise
whether the subject is from the first
hand or second hand.
17. I deduced regarding the explained
matter and I can evaluate the reasons of
these deductions.
18. I can pass an accurate judgement on the
matter, and I can come to a conclusion
with my thoughts.
19. By means of my thoughts, I can make
comments and can judge the matters.
20. When I encounter a matter, I can
express my thoughts regarding matter
and can defend my opinion.
21. When I encounter a matter, I can
visualize it and can feel it as the main
character of the matter.

IIb. COLLABORATING SKILLS

5 4 3 2 1 Strongly
disagree
strongly agree Neutral Disagree
agree
1. I Listen to other people well
2. I am able to speak or argue
3. I Appreciate and Respect opinion of
my groupmates during activities
4. I initiate working together with my
groupmates to solve problems
5. I Discuss assignments with my
 classmates well
6. I Show concern for my groupmates
7. I am able to guide others to achieve
goals
8. I share my insights to my groupmates
and in the class
9. I always recite to the class my ideas
and opinion on the said topic
Attendance
10. I always attend the class and meetings
required
11. I am always late to attend the class
and meetings required
12. I always arrive early to attend the
class and meetings required

IId. CREATIVE THINKING SKILLS

5 4 3 2 1 Strongly
disagree
Fluency strongly agree Neutral Disagree
agree

Summarizing 1. I can Answer

the answers questions with facts

Critiquing the 2. I can see the

objects or mistakes of objects
situation or situations

Producing 3. I am Fluent to
ideas generate ideas

Flexibility

Attributing 4. I can Give point of

situation view about some
situation
Organizing 5. I can Organize
situation situation into
different category
Planning 6. I can Think and find
different some solutions to
answers specific problems

Originality
 Producing new 7. I can solve and
things Finish new kind of
problems
Differentiating 8. I can Enrich the idea
ideas from previous
discoveries
Elaboration

Planning to 9. I Seek deeper

solve problem meaning from a
with solution of a
procedural problem
ways

Generating 10. I can Create

something something new and
new different

Part III

IIIa. SOCIAL FACTORS

Social Relationship 5 4 3 2 1 Strongly

disagree
strongly agree Neutral Disagree
agree

1. I can’t concentrate on my studies

whenever my partner and I have
misunderstandings
2. I often miss my classes because of
hanging out with my partner

3. I can’t fix my attention on my studies

because i feel worried that this romantic
relationship won’t work out
4. I am having a hard time focusing on my
studies when me and my partner are not
in good terms
5. I feel worried about my studies because
my parents might know that I’m
involved in a relationship
6. I can still pass my projects and
homeworks on time even if im in a
relationship
7. I think i can get higher grades when im
in a romantic relationship

8. Im inspired to finish my course when im

in a romantic relationship

Sense of belongingness
9. I get support from my fellow students
when i need it

10. I feel understood by other students

11. I am accepted as myself

12. I find it easy socializing with other

students

13. I feel free to share my disappointments

at least one of my fellow students

14. It is important to me to feel accepted by

my fellow student

Social media and phone usage

15. I sleep late because of using social media
platforms to entertain me

16. I make or receive calls when im in a

class/lecture

17. I find myself occupied on my mobile

phone when i should be doing other
things
18. I find it difficult to communicate in
person than through phones

19. I feel distracted when i dont have my

mobile phone with me.

20. My productivity had decreased as a

direct result of the time i spent on my
phone
21. There are times when i rather use my
phone than deal with more pressuring
issues
 Student organization
22. Worked with classmates outside class to
prepare for a project

23. Worked on a paper or project that

require integrating ideas or information
in various sources
24. Worked harder than you thought you
could to meet an instructors standards
or expectations
25. Worked with faculty members on
activities other than coursework

26. Received prompt feedback from faculty

on your academic performance

IIIb. PHYSIOLOGICAL FACTORS

5 4 3 2 1 Strongly
disagree
Physiological skills strongly agree Neutral Disagree
agree

1. I like to do exercises and drills in class

2. I concentrate better when I move

around (e.g., pacing or my tapping feet).

3. I understand better things in class when

I participate in role-playing

4. When someone tells me how to do

something in class, I learn better

5. When I do things, I learn better

6. I get more work done when I work with

others

7. I learn more when I can model of

something

8. When I speak, I move my hands a lot to

express myself better
 9. I prefer hands-on activities to learn
better

10. I prefer to learn by moving around and

doing something in class

11. I am physically oriented and move a lot.

12. I like being involve in physical activities.

13. I memorize by walking and seeing.

14. I use a finger as a pointer and gesture a

lot.

15. I want to act things out.

16. I respond to physical rewards.

17. I touch people to get their attention.

IIIc. ENVIRONMENTAL FACTORS

Learning facilities
1. The availability of study space
(classroom and accommodation)
supports my academic achievement in
the school.
2. The school library is well stocked with
relevant reading materials for learning
to improve my performance
academically.
3. The computer laboratory is adequately
stocked with computers for my
learning.
4. The entry qualification (matric results)
of students is a predictor of good or bad
academic performance
5. Availability of qualified nurse educators
ensures positive learning outcomes in
terms of student achievements.
6. The teaching strategies used by the
nurse educators help me to understand
the topic(s) under discussion during
lessons which also improve my
academic performance.
7. Institutional library personnel offer
orientation and demonstration of the
 library services
8. Library personnel provide assistance to
students when needed
9. Library is user friendly for nursing
students
10. Library has sufficient materials to
support programme or classroom
assignments
11. Library operating hours are convenient
for students
Proper guidance
12. Parents’ involvement in the education
of their children is a good predictor of
better academic performance of
students.
13. Students whose parents are literate
have greater advantage in their
academic performance than those
whose parents are illiterate.
14. Academic support services offered by
teachers help improve my academic
performance.
15. Adequate support given at the clinical
area during clinical attachment improve
my practical skills and academic
achievements.
Physical Classroom Environment
16. Classrooms are pleasant places to work
17. Lighting is adequate and there is no
glare
18. Ventilation is sufficient and the
temperature is appropriate
19. There is adequate space for movement
20. Furniture is arranged to best effect for
different activities
21. Equipment and materials are easily
accessible (computer, lighting system,
projector, overhead projector)
22. Adequate seating arrangements for
students
23. Students have adequate personal
workspace
24. Students can easily see the teacher and
the black or white board
25. Furniture is suitable and well
maintained
26. Sound level in classroom is conducive or
 favorable to learning
Digital resources
27. Computer laboratories are adequate to
support learning (research, assignment
completion, etc.)
28. Effective use of various mediums such
as online teaching and learning
(Ikamva)
29. Adequate resources for students during
online assessments
30. E-learning support services are readily
accessible to all students
31. Computer laboratories are available
outside regular classroom hours
32. Teaching And Learning Climate
33. Lecturers or clinical facilitators are
approachable
34. Lecturers or clinical facilitators are
concerned with developing my
competence
35. Lecturers or clinical facilitators are able
to communicate well with students
36. Lecturers or clinical facilitators have
shown patience towards students
37. Lecturers or clinical facilitators provide
good feedback to students
38. Lecturers or clinical facilitators give
students constructive criticism
39. Lecturers or clinical facilitators are well
prepared for classes
40. I feel free to ask whatever question I
want in class
41. The environment encourages me to
learn
Curriculum
42. I am sure about the programme
learning outcomes
43. The teaching and learning experience of
the previous year prepared me well for
this year
44. Time table arrangement allows for
academic engagement
45. Assessments are aligned to the
outcomes provided in module guides
46. The curriculum provides an appropriate
balance between theory and practice
47. The learning outcomes are appropriate
 for the year level
48. The curriculum is organised in a way
that facilitates my learning
49. The learning materials, including
module guides, work books and so on,
are clear
50. The programme thus far developed my
ability to apply theory to practice
51. The programme thus far improved my
problem-solving skills
52. The programme thus far developed my
ability to think critically about the
subject matter
53. The programme thus far helped me
understand current issues in the nursing
profession

Teaching Method
1. The instructor explained course content in a
way I could understand.
2. The instructor used teaching methods that
helped me learn.
3. The instructor clearly presented the skills to
be learned.
4. The instructor was well prepared for class.
5. The instructor engaged the class in
productive discussions.
6. The instructor encouraged student questions.
7. The instructor used class time effectively.
8. The instructor communicated clearly.
9. The instructor effectively explained course
concepts.
10. The instructor encouraged student
participation in class.
11. The instructor presented course material in
a clear manner that facilitated understanding.
12. The instructor effectively organized well-
run learning activities.
13. The instructor’s teaching methods were
effective.
14. The instructor stimulated my interest in the
subject matter.
15. I received grades and feedback on
assignments/tests in a timely manner.
Availability of Resources
1. Equipment is functioning and ensures
learning opportunities.
2. It is readily available for simulation.
3. Provide realism of nursing skills practice.
4. There are sufficient equipment and supplies
in the simulation that can be used during the
nursing skills demonstration and re-
demonstrations.
5. The availability of equipment and supplies
affect the quality of my nursing skills
performance.
Teacher Absenteeism
1. I believe that teacher absenteeism
contributes to poor student achievement.
2. My classes are often affected from teacher
absenteeism.
3. I absent myself to school due to regular
teacher absenteeism.
4. I believe particular teachers are more absent
than others.
5. I continue with my studies during the
absence of the teacher.
6. I believe that there is a high level of teacher
absenteeism at the school.
7. The teacher tries to make up for lost time by
extending class time on his/her return to work.
8. I believe that negative student behavior is
escalated because of teacher absences.
9. I believe that student behavior has
contributed to teacher absenteeism.
10. On return to school, my teacher gives the
class a reason for being absent from work.

IIIe. COGNITIVE FACTORS

5 4 3 2 1 Strongly
disagree
strongly agree Neutral Disagree
agree

Learning Styles

1. When the teacher tells me the

 instructions I understand better.

2. I prefer to learn by doing something

in class.

3. I get more work done when I work

with others.

4. I learn more when I study with a

group.

5. In class, I learn best when I work

with others.

6. I learn better by reading what the

teacher writes on the chalkboard.

7. When someone tells me how to do

something in class, I learn it better.

8. When I do things in class, I learn

better.

9. I remember things I have heard in

class better than things I have read.

10. When I read instructions, I

remember them better.

11. I learn more when I can make a

model of something.

12. I understand better when I read

instructions.

13. When I study alone, I remember

things better.

14. I learn more when I make something

for a class project.

15. I enjoy learning in class by doing

experiments.

16. I learn better when I make drawings

as I study.

17. I learn better in class when the

teacher gives a lecture.
 18. When I work alone, I learn better.

19. I understand things better in class

when I participate in role-playing.

20. I learn better in class when I listen to

someone.

21. I enjoy working on an assignment

with two or three classmates.

22. When I build something, I

remember what I have learned
better.

23. I prefer to study with others.

24. I learn better by reading than by

listening to someone.

25. I enjoy making something for a class

project.

26. I learn best in class when I can

participate in related activities.

27. In class, I work better when I work

alone.

28. I prefer working on projects by

myself.

29. I learn more by reading textbooks

than by listening to lectures.

30. I prefer to work by myself.

Resourcefulness

1. Ask the Librarian for help.

2. Ask the learning disability specialist

or your resource room teacher for
help.

3. Ask a parent

4. Ask help from my resource room

teacher in learning better study
 skills.

Study Schedule

1. Aside a certain amount of time each

day for studying.

2. Study whenever you get the chance.

3. Plan a study schedule each week,

based on your assignments.

4. Study just on the nights before tests.

5. Study just enough to keep up

6. Write assignments on a calendar

according to when they are due.

Taking Tests

1. Wonder what will be on the test.

2. Lose points for incomplete answers.

3. Be confused about the directions.

4. Panic before or during the test.

5. Run out of time before completing

the test

Reading Books

1. Page through the book and set it

aside.

2. Get started by reading the first

chapter.

3. Look through the book at the study

questions, glossary, chapter
headings, and table of contents.

4. Set the textbook aside until class

begins.

Study Habits

1. Remember assignments for specific

classes.
 2. Finish assignments without being
reminded.

3. Set aside time from other activities

to study.

4. Finish an assignment once you’ve

started.

5. Keep your materials together

without loosing them.

6. Organize your books and materials

7. Read assigned textbooks, or book

length packs of course readings

8. Read on your own (not assigned) for

personal enjoyment or academic
enrichment

9. have written papers or reports to

study

Taking Notes

1. you didn’t take enough notes.

2. You have gaps in your notes.

3. You can’t write fast enough to keep

up.

4. You can’t understand your notes

when you go back to review them.

Memory

1. I am generally pleased with my

memory ability.

2. There is something seriously wrong

with my memory.

3. If something is important, I will

probably remember it.

4. My memory is worse than most

other people my age.

5. I am concerned about my memory.

 6. My memory is really going downhill
lately.

7. I worry that I will forget something

important.

8. after reading and studying, I

remember all of the important
concepts

Memory Strategies

1. Use a timer or alarm to remind you

when to do something.

2. Ask someone to help you remember

something or to remind you to do
something.

3. Create a rhyme out of what you

want to remember. want to
remember

4. Organize information you want to

remember

5. Say something out loud in order to

remember it

6. Use a routine to remember

important things

7. Mentally elaborate on something

you want to remember; for
example, focus on a lot of the
details.

8. Repeat something to yourself at

increasingly longer and longer
intervals so you will remember it.

9. Create a story to link together

information you want to remember.

10. Create an acronym out of the first

letters in a list of things to
remember
11. Intentionally concentrate hard on
something so that you will
remember it.

12. Write a note or reminder for

yourself

13. Mentally retrace your steps in order

to remember something