Questionnaire

___________________________________________________________________________
FIDELITY ON THE IMPLEMENTATION OF INTERVENTION AND SUPPORT
PROGRAM FOR STUDENTS-AT-RISK PRONE OF DROPPING OUT

A. Teacher’s Profile

Name: ___________________________________________ (Optional)

Directions: Put a check mark on the box provided under each item.

1. Gender: Male Female

2. Age
20 – 29
30 – 39
40 – 49
50 – 59
60 – above

3. Civil Status
Single
Married
Others ________________

4. Teaching Position
Teacher I
Teacher II
Teacher III
Master Teacher I
Master Teacher II
Master Teacher III

5. Educational Attainment:
Bachelor’s Degree
Units in Master’s Degree
Master’s Degree
Units in Doctorate Degree
Doctorate Degree

6. Length of Service as Teacher:

Less than 3 years
3 – 5 years
6 – 10 years
11 – 15 years
15 – 20 years
Above 20 years
 7. Number and Title of Trainings Attended Related to Intervention and Support
Program:
_____________________________________________________________________
_____________________________________________________________________

B. The extent of fidelity of intervention implementation of the different intervention and

support program practices.
Directions: Please read carefully. Put a check mark on the appropriate box of your choice that
corresponds to your answer regarding extent of fidelity of intervention on the management of
intervention and support program for learners-at-risk. Kindly answer honestly and use the
scale in the survey given below.

5 - Highly Consistent (HC)

4 - Consistent (C)
3 - Fairly Consistent (FC)
2 - Less Consistent (LC)
1 - Not Consistent (NC)

HC C FC L NC
Indicators 5 4 3 C 1
2
Adherence
1. Interventions are implemented according to the
plan.
2. Interventions are well aligned with core
curriculum.
3. Interventions are well articulated to the school
personnel.
4. Awareness-raising program are conducted in
school about the different social and emotional
issues.
5. Programs and activities are provided that motivate
students to participate on the intervention and support
programs.
6. I ensure to implement all the essential procedures
as prescribed in the intervention program.
7. I feel comfortable in the implementation of
different intervention program in school.
8. I apply teaching and learning interventions
objectives based on students need.
9. I am trained on the proper procedure and standard
in the conduct of intervention program.
10. I ensure that intervention program and activities
benefit to the change of students behavior.
11. I provide profiling and risk assessment to
students-at-risk.
12. I used screening tool and diagnostic assessment to
verify decisions about whether a students is at-risk or
not.
13. I established decision making rules in the
management of intervention.
14. I involve parents in decision making regarding
intervention protocol.
15. I can access individual students’ data on the data
management system whenever I track students profile
and records of interventions underwent.
Exposure
1. I exposed the students to intervention based on the
plan.
2. I am determine to expose students to necessary and
prescribe behavioural intervention as intended.
3. I ensure that students are expose to the length of
time needed for the instructional delivery of
intervention.
4. I ensure that students received intervention as often
as needed each week.
5. I ensure that I expose the students monitoring of
their progress at least weekly on a regular basis.
6. I follow procedure to ensure implementation
accuracy.
7. I engage students to particular program suitable to
his/her needs.
8. I use motivational techniques to help keep students
engage in the lesson.
9. I utilize differentiated activities for various types
of students.
10. I implement the essential procedures in the
conduct of intervention program.
Quality of Delivery
1. I adequately prepared to deliver the intervention
with knowledge of instructional strategies.
2. I interact to students with encouragement and
enthusiasm.
3. I provide clear and explicit instruction for the
students during intervention.
4. I provide positive and constructive feedback to the
students.
5. I ensure that the pacing and transitions of the
lesson are effective and appropriate for the students.
6. I respond to questions and communicate clearly to
students.
7. I provide and use supplementary materials to
conduct intervention.
8. I meet my objectives as evident to students’
success.
9. I provide time for my students to ask questions.
10. I provide extensive assistance and support to my
students.
11. I use positive discipline and non-violent approach
to student concerns.
12. I show appreciation and patience to conduct
intervention.
13. I coordinate with parents and community service
providers about the intervention program of the
students.
14. I support advocacy that promotes well-being of
the students.
15. I build school-community partners that promotes
awareness on pressing issues.
Program Specification/Differentiation
1. I implement intervention and support as they were
designed.
2. I demonstrate knowledge of content of intervention
strategy.
3. I apply knowledge on intervention strategies when
students might need a new program match to his
needs.
4. I adjust instructional technique as needed based on
my students’ profile.
5. I am aware of the level of students’ interest and
enthusiasm.
6. I offer individualized instruction or intervention
appropriate to students’ need.
7. I ensure to conduct home visitation service for my
students.
8. Students are exposed in guidance and counselling,
individual and peer counselling program.
9. Students are exposed in youth development
activities.
10. Students are engaged in values formation
activities.
11. Students are involved in health and nutrition
activities.
12. Students are exposed to remedial class such as
mentoring and tutorial.
13. Students are exposed to diversion program
provided by community service providers
(DSWD/PNP).
14. Students are exposed to flexible alternative
learning scheme that will develop literacy and
numeracy skills.
15. Students are exposed with the use of technology-
mediated instruction.
Student Responsiveness
1. Students are engage on intervention program.
2. Students are authentically and actively engage on
intervention program.
3. Students are responding well to intervention
program.
4. Students are able to get support coming from their
parents that undergo intervention program.
5. Students show willingness and enthusiasm to
engage in intervention activities.
Leadership
1. School personnel understand the program that
prevent students of having academic and behavioral
problems.
2. Staff proactively support the essential components
of the response to intervention program of the school.
3. Support for response to intervention program is
prioritized in school.
4. Designated multi-disciplinary team who oversee
and manage the implementation of intervention
program is created in school and meet regularly.
5. Response to intervention training, seminars, and
professional development is made available and
provided to school personnel.
6. Intervention materials and facilities are provided.
7. School personnel continuously reflect and improve
the delivery of instructional practice and decision
making.
8. Schedules are provided adequately manage
students’ exposure and time for intervention.
9. Parents are informed about the decision making
regarding the progress of their students who is
receiving intervention.
10. Management structure and clear process are in
place that guide stakeholders in their involvement on
the intervention program.

SUBMITTED BY:
(Signature over printed name)

JOCELYN T. AQUINO

JOSEPH R. CARREON