SURVEY QUESTIONNAIRE

Personal Profile
Name:________________________________________________________________________
Address:______________________________________________________________________
Nationality:______________
a. Sex: _________male ________ female
b. Age: _______________ c. Occupation: __________________
d. Income level: _____below 5,000 _____6,000 10,000 _____ 11,000 15,000
_____ 16,000 20,000 ________ 20,000 above
Instructions: Please write a check mark of your choice on the space provided for each item.
1. Are you using purified water as your drinking water?
_____ YES ______ NO
2. How aware you are regarding the safety and cleanliness of water you drink?
_____ very much aware _______ much aware _________ not aware
3. From what source does your drinking water comes from?
_______ deepwell _____ water pump _____ water refilling station
4. How often do you buy bottled water in a day?
______ 1 time ______ 2 times ________ 3 times or more
5. What size of bottled water do you buy normally?
____ 330 ml ____ 500 ml _____ 1L _______ 5 gal
6. How many bottles of of this size. do you drink per day?
_____ 2 ________ 3 _______ 4
7. What kind of water do you prefer to drink?
________ purified __________ alkaline _________ distilled
8. How many are you in a household?
____ 2 5 ____ 6 -10 _______ more than 10 (please specify)
9. How many containers of purified water your household can consume in a day?
________ 1 -2 ________ 3 4 _________ 5 ________ 6 or more
10. Where did you usually purchase your drinking water?
____ Gold Swan ____ Bio Crystal ____ Aquatek ________ others (please specify)
11. What problems do you encounter when buying you drinking water?
_____ distance _____ availability of product _____ price _______ service
12. Aside from drinking water what are the uses of purified water in your household?
_________ cooking _______ bathing _______ washing ________________ others
13. Buena Agua Refilling Station is currently attempting its establishment in Barangay
Buenavista. Which best describe your opinion on these efforts?
______ Very Positive ______ Somewhat Positive _______ Negative
14. Would you consider patronizing a water refilling station if one were located in your
barangay?
_____ YES _______ NO
15. Using the list below what factors would most influence you to patronize a water refilling
station.
____ location _____ quality service _____ convenience ______ cost
16. How much are you willing to spend for a 1 container refill?
_____ 10 _____ 18 _____ 20
17. Do you already have purified drinking water dealer?
________ Yes ________ No
18. Do you agree for 30 minutes span for the delivery?
___________ yes ___________ no
19. If we offer purified drinking water are you willing to try?
________ yes ________ no
20. Will it be possible that you can be our first and loyal customer?
__________ yes __________ no
21. How do you want us to reach you to take your order?
_______ telephone/mobile _______ personal
22. If you have any suggestions with the proposed study feel free to comment below.
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