A research questionnaire to determine the prevalence of diarrhea.

1. PREVALENCE AND PREVENTIVE MEASURE SCALE OF DIARRHEA
Part 1- Prevalence Rate
Instruction:
1. Please put a check (√) mark in between parentheses before the options (family member)
written below.
2. Please write your answer on a specific question asked.
3. Please answer honestly.
Number of times diarrhea
1. Who among the family members had experienced occur
diarrhea for the past six (6) months? None or 2-3 4 times
once only times and more
( ) Father - Please indicate your age: ( )
( ) Mother -Please indicate your age: ( )
( ) Child/Children: Please specify the child’s first name and
age below.
Name Age
___________________ _____
___________________ _____
___________________ _____
___________________ _____
( ) Other relatives living with you. –Please indicate the
age ( )
( ) None of your family members.
Part 2- Preventive Practices
1. Please read each item carefully and answer honestly to what extent you practice preventive
measure based on a given description every item.
2. Do not leave any item unanswered
3. Give each item a rating by putting a check (  ) mark according to the following scale that
describes:
1-Never or Barely 2-Often 3-More often 4-All the time
1- Never 2 - 3- 4 -All
1. Do you practice hand washing; or Barely Often More the
often time
1.1 before and after you touch specifically wet food
products eating meal
1.2 after touching assisting member in the bathroom,
changing diaper or feeding and playing with your pet
1.3 after using the toilet for waste disposal/urination
1.4 after cleaning and disposing garbage

2. 1.5 when preparing and cooking meal
3- 4 -All
1- Never 2 -
2. Do you practice personal hygiene by; More the
or Barely Often
often time
2.1 Maintaining nails short/trimmed and clean
2.2 Bathing regularly at most everyday
2.3 Changed soiled clothing regularly (Specifically
underwear)
2.4 Maintain hair combed, tied or secure (specifically
while cooking) and regularly wash
2.5 Everybody in the family wear slippers
3- 4 -All
1- Never 2 -
3. In food storage and preparation do you practice by; More the
or Barely Often
often time
3.1 separate dry food product from wet food
3.2 washing the food thoroughly before slicing or
preparing it
3.3 re-heat left- over food before eating or serve
3.4 put food products in a low/cold temperature
(refrigerator) and in a close container
3.5 cooking food in a required temperature
3- 4 -All
1- Never 2 -
4. How the way you and your family eat meals? More the
or Barely Often
often time
4.1 Do you usually use spoon and/or fork when eating
meal
4.2 Do you avoid buying food from any street vendor
for regular meals intended to your family
4.3 Do you/and any of your family member store left-
over food in a close container and refrigerate
4.4 Do you and your family avoid sharing or use same
utensils (Plate, spoon or glass) when eating
4.5 Does your mother or other member impose a strict
rule to eat only in the kitchen/dining room and not
anywhere in your house
3- 4 -All
5. How is your water supply available and store in 1- Never 2 -
More the
your home? or Barely Often
often time
5.1 Do you boil/filter water for drinking if it is from
deep-well or just tap water

3. 5.2 Do you stored water for drinking in a refrigerator or
water dispenser
5.3 Do you make sure that your water boiled properly
for hot beverages and/or milk formula
5.4 Do you usually make your own ice cubes/ice water
for your cold beverages
5.5 Do you secure enough water supply at home for
everyday needs to prevent shortage
3- 4 -All
1- Never 2 -
6. How the way you set-up things in your home? More the
or Barely Often
often time
6.1 Do you always apply Lysol, chlorine or other
disinfectant in cleaning the house specifically in the
kitchen and toilet area
6.2 Do you keep things in order to avoid clutters in the
house specifically unwashed dishes in the kitchen sink
6.3 Do you find means to terminate rats, cockroaches
and flies if present in your house
6.4 Do you practice garbage segregation and
appropriate garbage disposal in your home
6.5 Do maintain your drainage system free from
clogging and odor specifically in sink and toilet bowl.
7. What do you and your family members promote & 3- 4 -All
1- Never 2 -
develop biologically as preventive healthcare More the
or Barely Often
practice? often time
7.1 Did you breastfed your baby?
7.2 Do you/any of your members specially kids takes
vitamin supplement
7.3 Do you and your family members nourish well
7.4 Do you and your family engage in any recreational
activities (sports, exercise, etc.)
7.5 Did you or your family members practice bringing
anywhere and using alcohol or any sanitizer when
travel?