Sample of Questionnaires: Survey Question and Likert Scale Questionnaire.
The sample of questionnaires has been collected from University Putra Malaysia. New researchers will get a concept on how to create a survey questionnaire. This sample of questionnaires represents an example of questionnaires.
Sample of Questionnaires
Dear respondent,
We are KOM3431 Communication Research Students from the Department of Communication, Faculty of Modern Languages, and Communication. We are currently doing our individual assignment on data analysis. We wish to collect some information about your awareness of obesity.
You are invited to participate in this survey in which your insight and information are valuable for us to strategize the health communication campaign to be more effective. We greatly appreciate your help in providing us your honest answers to the questions below. I reassure you that the information gathered in this survey will only be used for event purposes and will be kept confidential.
Thank you.
SECTION A: DEMOGRAPHIC
| 1 | Ethnic | : | □ Malay | □ Indian | ||
| 2 | Gender | : | □ Chinese | □ Other: ______________ | ||
| □ Male | □ Female | |||||
| 3 | Age | : | □ | Below 15 | □ | 31–35 |
| □ | 15–19 | □ | 36–40 | |||
| □ | 20–25 | □ | 41–45 | |||
| □ | 26–30 | □ | Above 45 | |||
- Which written language(s) do you understand? (Choose whichever relevant)
| □ | Malay | □ | English | |
| □ | Chinese | □ | Tamil |
- Which spoken language do you prefer? (Choose one (1) ONLY)
| □ | Malay | □ | English | |
| □ | Mandarin | □ | Tamil | |
| □ | Cantonese | □ | Hakka | |
| □ | Hokkien | □ | Other: ___________ |
SECTION B: MEDIA CONSUMPTION
- What are the main sources you use the most to obtain health information? (Choose minimum one (1) answer and maximum three (3) answers)
| □ | Newspaper | □ | Internet |
| □ | Magazine | □ | |
| □ | Television | □ | |
| □ | Radio | □ | |
| □ | □ | Other: ______________ |
- If you have selected a newspaper as one of the sources for obtaining information pertaining to health, which newspaper vehicle do you read the most? (Choose one (1) ONLY)
| □ | Sin Chew Daily | □ | Guang Hwa Daily |
| □ | China Press | □ | Oriental Daily |
| □ | Nanyang Siang Pau | □ | The Star |
| □ | Utusan Malaysia | □ | Berita Harian |
| □ | Kosma! | □ | News StraitTime |
| □ | Guang Ming Daily | □ | Other: ______________ |
SECTION C: MEDIA PREFERENCE
- Do you watch local television (TV) station(s)?
- Yes (Proceed to Q2)
- No (Proceed to Q4)
- How many hours of TV do you watch in a day? (Choose one (1) ONLY)
- Less than 1 hour per day
- 4-6 hours per day
- 1-3 hours per day
- More than 6 hours per day
- Which TV channel you watch the most? (Choose one (1) ONLY)
| □ | Astro | □ | NTV 7 |
| □ | RTM 1 | □ | 8TV |
| □ | RTM 2 | □ | TV 9 |
| □ | TV 3 | □ | Other: ______________ |
- Do you listen to the local radio?
- Yes (Proceed to Q5)
- No (Proceed to Q7)
- How many hours of local radio station do you listen in a day? (Choose one (1) ONLY)
- Less than 1 hour per day
- 1-3 hours per day
- 4-6 hours per day
- More than 6 hours per day
- Which local radio station you listen to the most? (Choose one (1) ONLY)
| □ | One FM | □ | Hitz.FM |
| □ | 988 FM | □ | Fly FM |
| □ | Melody FM | □ | Lite FM |
| □ | MY FM | □ | Mix FM |
| □ | Ai FM | □ | Era FM |
| □ | Red FM | □ | Hot FM |
| □ | Sinar FM | □ | Other: ______________ |
- Which social media do you use the most? (Choose one (1) ONLY)
| □ | □ | ||
| □ | □ | ||
| □ | □ | Other: ______________ |
SECTION D：Awareness about Obesity
Tick (✓) the spaces provided to indicate your level of agreement with the statements below.
I. Problem Recognition
| No | Statements | Strongly
Disagree/ 1 |
2 | 3 | 4 | Strongly
Agree/ 5 |
| 1 | Obesity is becoming an increasingly large problem in my community. | □ | □ | □ | □ | □ |
| 2 | There is an urgent need to solve the obesity problem in my community. | □ | □ | □ | □ | □ |
| 3 | There is much room for local authorities and the government to improve the policies in controlling obesity in Malaysia. | □ | □ | □ | □ | □ |
| 4 | I believe the prevention of obesity is very important. | □ | □ | □ | □ | □ |
II. Constraint Recognition
| No | Statements | Strongly
Disagree/ 1 |
2 | 3 | 4 | Strongly
Agree/ 5 |
| 1 | I am not able to do anything to solve the obesity problem in my community. | □ | □ | □ | □ | □ |
| 2 | My efforts to combat the obesity problem in my community is pointless. | □ | □ | □ | □ | □ |
| 3 | I do not see any points in trying to encourage my community members to control their weights. | □ | □ | □ | □ | □ |
| 4 | I think I could not affect my community members to control their weight and to prevent obesity. | □ | □ | □ | □ | □ |
III. Involvement Recognition
| No | Statements | Strongly
Disagree/ 1 |
2 | 3 | 4 | Strongly
Agree/ 5 |
| 1 | I am concerned that overweight is affecting my life. | □ | □ | □ | □ | □ |
| 2 | I believe obesity could affect my health. | □ | □ | □ | □ | □ |
| 3 | I have a strong opinion about obesity. | □ | □ | □ | □ | □ |
| 4 | I feel that obesity affects me personally. | □ | □ | □ | □ | □ |
– – End of Survey Questionnaire – –
Thank you for answering.