Department of Education

Region III
Schools Division Office of Bataan
Mariveles National High School
Camaya Campus

Dear Respondent,
The researchers are from Grade 12 ABM-A students in Mariveles National High
School-Camaya Campus. The purpose of this study is to determine the impact of nutritional
status to the academic performance of 12 ABM-A. Answering questions will only take 15
minutes of your time. Also, the researchers promise that your personal information and
responses will be treated with confidentiality. Your participation in the study is voluntary, you do
not have to answer questions that makes you uncomfortable. Thank you for your time.

Shella Marie Palad

John Marlou Gaspar
Dames Elise Sabellano

Direction: Please fill in the following Demographic profile.

1. DEMOGRAPHIC INFORMATION
Name: (optional) ________________________
Sex: ________ Age: _______

Direction: Please check (✓) the following BMI classification which corresponds to your physical
appearance.
2. BODY MASS INDEX (BMI)
Underweight Overweight
Normal Obese

Direction: Please check (✓) the most appropriate response.

3. INTAKE OF BREAKFAST
3.1 Do you take breakfast in the morning before coming to school?
Yes No Not always
3.2 If yes, what do you take?
Rice Vegetables Bread Meat, eggs, fish, milk Fruits
 3.3 If not always, what do you take?
Rice Vegetables Bread Meat, eggs, fish, milk Fruits

Direction: Please respond to the following by placing a check (✓) mark in the Yes or No column.

4. EATING HABITS. I prefer to eat the following….

Question Food Examples Yes No

Number Group
1. Cereals Bread, noodles, biscuits, cookies, and
others
2. Vitamin A Carrots, squash, or sweet potatoes, leafy
rich vegetables. Fruits like ripe mangoes,
vegetables papayas, and others.
And fruits
3. Organ Liver, kidney, heart, or blood-based foods
meat
4. Flesh Beef, pork, goat, chicken, duck, or other
meats birds
5. Eggs
6. Fish Fresh or dried fish or shell fish
7. Nuts & Beans, peas, nuts, seeds, and others
Seed
8. Milk Milk, cheese, yogurt, or other milk products
products
9 Oils and Oil, fats, or butter added to food or used for
fats cooking
10. Sweets Sugar, honey, soda, chocolate, candies
11. Coffee/ Tea (black, green, herbal) or coffee
Tea

Direction: Please indicate your response to the following statements by circling the letter
which more correspond to your evaluation.

5. SOCIO-ECONOMIC STATUS. House built

 wall
A. Mud B. Blocks C. Wood D. Others (specify)

 floor
A. Mud B. Cemented C. Others (specify)

 What are the two main sources of energy you use for cooking?
A. Wood B. Charcoal C. Gas D. Electricity E. Others (specify)
6. HYGIENE AND SANITATION

 What are the two main sources of water that you use at home?
A. Dam. B. Piped water. C. Wells. D. Others

 Do you treat your drinking water?

A. Yes. B. No

 If yes, which of the following methods do you use?

A. Boiling. B. Chlorination. C. Others

 Do you have toilet at home?

A. Yes. B. No

 If no, where do you go?

A. Open field. B. Behind the house C. Others

 At what times do you wash your hands? (multiple answers are possible)

A. After visiting the toilet. D. When I think that they are dirty
B. Before eating. E. When water is available
C. Before preparing food F. Other (specify

Form by: Kikete Joseph Wanjala and Pearson Pearson NCS MM64979-1

Direction: Kindly tick (|) the most appropriate response.

7. PERFORMANCE OUTCOME
7.1 What is your last school year’s final average (2nd Semester SY 2017-2018)
79 and below 80-84 85-90 91-95 96 and above
7.2 Do you excused in the class for personal reasons (like health reasons?)
Yes No
7.3 Do you miss class in the school?
Always Sometimes Never
7.4 Do you participate in a group or class discussion in your school?
Always Sometimes Often Never