Sample Questionnaire
Name (optional): ________________________ Year & Section: ________________
Age: ____ Sex: ________
Directions: Please indicate how much you agree or disagree with each statement in the
survey by checking the box on the right side of each statement. There needs to be correct and
correct responses. Identity will be hidden, and your responses will be handled in the strictest
confidence.
Scale: 5 - Yes
4 - Often
3- Sometimes
2 - Rarely
1 - Never
5 4 3 2 1
A. Social Media Yes Often Sometimes Rarely Never
1. Have you ever missed a deadline or failed to
complete an assignment due to social media
distractions
2. Do you spend (insert #of hrs) on social media
per day?
3. Does social media distract you from
completing your schoolwork?
4. Did you stay up late using social media and as
a result, had trouble concentrating in class the
next day?
5. Do you feel that social media has a negative
impact on your ability to manage stress and
anxiety related to schoolwork?
6. Do you feel that social media usage affects
your mental health and well-being?