FEEDBACK AND SURVEY FORM

(SCHOOL)

Name Date
School
Position

1. Please check one or more boxes on the learning delivery modalities that the school
implements for SY 2020-2021.
 Printed Modules
 Digital Modules (Downloadable, CDs, DVDs, USB)
 Online (Synchronous) Distance Learning
 Online (Asynchronous) Distance Learning
 TV/Radio Based Instruction
 Others __________________

2. What learning materials does your school provide to parents/students?

 Self-Learning Modules
 Activity sheets
 Textbooks
 Workplans
 Others ____________

3. How do you furnish the learning modules to the designated recipients?

 Home delivery
 Pick-up in Schools
 Pick-up in other designated points _________________
 Others ___________________

4. How often does a parent / student need to go to school for picking up /dropping off the
modules/activity sheets?
 Once a week
 Every 2 weeks
 Once a month
 Once every grading quarter
 Others ________________

5. What is the ratio of the printed module to students?

 1 module: 1 student
 1 module: 2 students
MODE OF PRINTING AND DELIVERY OF LEARNING RESOURCES
6. Does the school procure for printing and/or delivery of learning modules?
 Yes, through ___________________  No
(Mode of Procurement)

7. Does the school conduct in-house or by-administration printing and/or delivery?

 Yes, printing and collating of learning modules are being done by ___________________.
___________________________________________________________________________
 No

8. Does the school enter into a partnership agreement with LGU?

 Yes  No

9. If your answer to No. 8 is Yes, what is the support you receive from LGU in relation to the
Basic Education Learning Continuity Plan (BE-LCP)? Please explain your answer.
 Grant of actual Special Education Fund (SEF) contribution_________________________
________________________________________________________________________

 Equipment and Supplies, ____________________________________________________

________________________________________________________________________
 Others __________________________________________________________________
________________________________________________________________________

10. Does the school enter into a partnership agreement with other eligible entities?
 Yes, __________________ provides _________________________________________

(Entity)
_____________________________________________________________________________

 No

11. What are the various assistances you receive from SDO in relation to the BE-LCP?
 The SDO mainly provides the printed materials.
 SDO provides additional fund support to the school.
 Others, __________________________________________________________________
________________________________________________________________________

12. Did the school find other ways to augment the fund for the printing of learning resources? If
yes, how? __________________________________________________________________
___________________________________________________________________________
(For teachers)
LEARNING MODULES
13. Below are the errors that you might have observed in the modules. Kindly identify the
estimated number of errors you have found to date:
Errors No. of errors found
0 1 to 3 4 to 6 7 to 10 10 to 20
Factual errors     
Computational Errors (Math related)     
Format (Font / Illustration)     
Printing errors (color) / Sorting of Pages     
Spelling / Punctuation / Typographical errors     
Grammar / Syntax     

14. Was the school able to distribute the modules and other learning materials on time?
 Yes  No

15. If your answer is No in No. 14, how long was the delay in the distribution of modules?
 1 to 3 days  4 to 8 days  9 to 15 days  15 to 30 days

16. In relation to No. 15, what are the reasons for the delayed distribution of modules? Pls.
expand your answer/s.
 Shortage of resources, ______________________________________________________
___________________________________________________________________________
 Delayed release of digital copies of modules to be printed__________________________
___________________________________________________________________________
 Delayed procurement for printing, ____________________________________________
___________________________________________________________________________
 Problems encountered on the delivery of module to students ________________________
___________________________________________________________________________
 Late pick-up of module by the parents / students _________________________________
___________________________________________________________________________
 Others __________________________________________________________________
__________________________________________________________________________
Please use the following scale in your assessment of the mode of learning and learning
materials adopted by the school.
1 = Strongly Disagree; 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree

No. Criteria 1 2 3 4 5 Remarks

17. On the Use and Content of the Learning Modules and Materials
17. The lessons in the Self-Learning Modules are
1 well-organized.
17. With minimal adult supervision, the module has
2 adequate information and activities that enable the
students to learn independently.
No. Criteria 1 2 3 4 5 Remarks
17. The instructions in modules are clearly stated and
3 can be well understood by the student.
17. The practice tests and activities provided are age-
4 appropriate.
17. The questions and activities are at different levels
5 of difficulty and stimulates the student’s reasoning
and creativity.
17. The number and kind of questions/activities in the
6 module can be answered by the students within the
given time frame.
17. The contents, information, and illustrations in the
7 module are consistent with moral values and
proper conduct.
17. Overall, I am satisfied with the quality of the
8 module which provides a good learning
opportunity and supports independent learning.
18. On the distribution and retrieval of Learning Modules
18. I find the mode of distribution quick and efficient.
1
18. The school’s manner of distribution and retrieval
2 of modules is acceptable and not bothersome for
the teachers.
18. Safety prevention protocols are observed during
3 the distribution and retrieval of modules.
19. Monitoring of Progress
19. I can easily and promptly give feedback on the
1 learners’ output to the students/parents.
19. I can easily reach the students/parents for learners’
2 remediation or assistance, if needed.

20. Are you overall satisfied with the effectiveness and efficiency of the implementation of
modular distance learning? Please state your reasons.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

21. Do you have any further concerns, suggestions, and feedback to improve the implementation
of BE-LCP?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________