Questionnaire Template with Instructions and Explanations
Every survey instrument or questionnaire should come with a cover letter in which you explain the study in some detail and motivate the potential respondents’ cooperation. You should also explain who has approved the study locally (i.e., the gatekeeper known to the potential participants). If possible, that person should also write a cover letter requesting the potential respondents’ cooperation.
[Questionnaire Title]
Statement of Informed Consent[1]
You are being asked to participate as a volunteer in a research study conducted by ______, a doctoral student at Pan-Africa Theological Seminary (PAThS). This study is designed to gather information about ______[briefly stated: a more detailed explanation should appear in your cover letter]. The research is being conducted under the supervision of Dr. ______, Dr. ______, and Dr. Chuck Wilson.
You will be one of approximately _____[state number]______[state who: people, pastors, women, etc.] participating in this study by completing this questionnaire.
1. Your participation in this project is voluntary; you will not be paid for your participation. You may withdraw from the study at any time without penalty or harm of any type. If you decline to participate in or choose to not complete the questionnaire, the researcher will not inform anyone of your decision, and no foreseeable negative consequences will result.
2. Completing the questionnaire will require approximately ___ minutes. There are no known risks associated with completing the questionnaire. If, however, you feel uncomfortable in any way during this process, you may decline to answer any question, or not complete the questionnaire.
3. The researcher will not identify you by name in any report using information obtained from your questionnaire; your confidentiality as a participant in this study will remain secure. Subsequent uses of data generated by this questionnaire will protect the anonymity of all individuals.
4. This research effort and this questionnaire have been reviewed and approved by the Dissertation Proposal Review Board, which functions as the Institutional Review Board for ethical research at PAThS. For research-related problems or questions regarding ethical research practices, please contact Dr. Chuck Wilson or Dr. Marvin Gilbert at
For further information, including a copy of the results of this study, please contact:
______[the researcher]
______[the researcher’s contact details]
NOTE: By completing and submitting this questionnaire, you are indicating that you understand the statements above, and consent to participate in this study.Do not put your name on the questionnaire; your signature acknowledging that you understand the information presented above is not required.
Common Demographic Variables[2]
What is your gender? Male Female
Use only one line for this question if the questionnaire is being completed on paper. Note the use of five spaces between the two choices; this creates a clear visual separation between one choice (Male) and the next tick box. Place the response (tick) box one space to the left of the response option (as above).Ensure every question is numbered.
How old are you? ___ years [fill-in response option]
In what year were you born? 19___ [fill-in response alternative:if asking directly for age is not appropriate.]
Note: the format “20___” would be needed above in a questionnaire designed for children.
How old are you? (tick one of the choices at right)..... / Under 25 years of age25–34 years of age
35–44 years of age
45–54 years of age
55–64 years of age
65–74 years of age
75 years of age or older
The tick-responseoption immediately abovewould be relevant fora survey of an adult population (or sample from such a population). Often, PAThS researchers survey adults serving in leadership or ministry positions; the age categories for children and youth must not be included in such adult-focused surveys.
How old are you? (tick one of the choices at right).... / 12–13 years of age14–15 years of age
16–17 years of age
18–19 years of age
20–21 years of age
22–23 years of age
24 years of age or older
If the study is focused on school-aged youth, the researcher should create meaningful age categories, as suggested above. The same principle would apply to any other age-limited group (e.g., children, retired adults).
What is your marital status?...... / Single(tick one of the choices at right) / Married (legal or registered)
Explain in the space below if more than one / Married (traditional or unregistered)
marriage is involved. / Divorced
______/ Separated
______/ Widowed
______/ Other: ______[explain]
Use the tick-response option above if you know (or suspect)some respondents are in polygamous or traditional marriages, and knowing this would be important to the study.
What is your marital status? ______[fill-in response option]
Other demographic variables that might be useful in a research questionnaire:
- What are the ages of your children?[3][ask only if essential to the study]? ______[fill-in response option]
- How many years have you been a Christian? ___ years [fill-in response option; ask for months in some cases]
- How many members and adherents currently attend your church? ____people [fill-in response option]
- How many years have you been a member of this church? ___ years [fill-in response option]
What is your highest educational qualification-accomplishment? ______[fill-in response option]
What is your highest educational qualification-accomplishment? (tick one of the choices at right) / High school graduation (with a school-leaving certificate; e.g., “matric”; “O”-level exams)Trade/technical/vocational training
Some academic credit (no qualification earned)
Diploma or associate’s degree
Bachelor’s degree
Postgraduate diploma or BA Honours
Master’s degree
Professional degree
Doctorate degree
The categories in the tick-response option above must be (1) inclusiveso everyone can answer, (2)adjusted to fitthesample being surveyed, and (3) adjusted to reflectthe local or national terminology used (e.g., “la maîtrise” in Francophone educational systems) . This adjustment in terminology mustgo beyond language translation because Africa’s educational systems vary greatly.
What is your primary ministry position? ______
The fill-in response option above allows respondents to phrase the response as they choose. The results are more difficult to analyze than the fixed-choice (tick-response) options below. The researcher must code each hand-written response in order to create meaningful categories for later qualitative and quantitative analysis.
What is your primary ministry position?...... / Pastor(tick only one of the choices at right) / Youth leader
Evangelist
Missionary
Men’s ministries leader
Other: ______
The categories abovein the tick-response optionmust (1) be inclusive so everyone can answer, (2) be adjusted to fit the group being surveyed, (3) reflect the purpose of the survey, and (4) employ the terminology used by the respondents.
How long have you held this position? ___ years [fill-in response option]
What is your current annual income? ______[fill-in response option]
What is your current annual income?) / Less than $20,000(tick only one of the choices at right) / $20,000 to $29,999
$30,000 to $39,999
$40,000 to $49,999
$50,000 to $59,999
$60,000 to $69,999
$70,000 to $79,999
$80,000 or more
The categories abovein the tick-response option must(1) be inclusive so everyone can answer, (2) align with the local financial realities and demographics, and (3) reflect the local currency. Specifically, the “$” sign must be replaced with the internationally recognized symbol (or term) of the currency used by the respondents.
In some surveys, the question above may need to be rephrased (e.g., Whatwas your personal income last year?).
Do not ask this question unless the information is essential to the study. Never ask questions out of curiosity.
Attitude-Opinion Variables
Likert-Scaled Items
Instructions: Please carefully read each of the following statements and respond by ticking the response box that best reflects your opinion. Please be completely open and honest in your responses. Take as long as you need, but do not linger over any statement.
Strongly Agree / Agree / Uncertain or Neutral / Disagree / Strongly DisagreeFirst statement to be judged-evaluated...... / / / / /
Second statement to be judged-evaluated...... / / / / /
Third statement to be judged-evaluated...... / / / / /
One of the keys to an effective Likert-scaled questionnaire is respondent persistence. Any item that confuses, threatens, or fatigues a respondent must be reworded or eliminated. This is one reason pilot-testing a new questionnaire is so important.
The sequence of statements in a Likert-scaled questionnaire is important: the longer the instrument (i.e., the greater the number of statements included in the left column), the more important item placement becomes. Difficult or emotionally charged items should be placed near the end of the instrument.
Semantic-Differential Items
Instructions:Rate ______[fill in with a person/group/event/object/practice] on each of the following ___ dimensions.
Tick the box between the opposing (contrasting)adjectives that best represents the strength or intensity of your feelings about ______[fill in with a person/group/event/object/practice].
A ticknext to one of the words indicatesa very strong feeling:..DecisiveIndecisive
A ticknear the middle indicates a fairly weak feeling:...... Good Bad
A tick in the center (mid-point)box indicates you are undecided:.Active Passive
(or do not understand the words themselves)
Please work quickly. Thereare no right or wrong answers.
Strong / / WeakDecisive / / Indecisive
Good / / Bad
Cheap / / Expensive
Active / / Passive
Lazy / / Industrious
A semantic differential scale requires respondents who are intelligent, cooperative, and comfortable withthe language used in the scale. They must also be able to make fine distinctions without undue struggle or hesitation.
To avoid respondent fatigue or boredom, avoid using an excessive number of adjective pairs; strive to not use more than 20 adjective pairs (lines): 10 to 12 adjective pairs may be adequate.
A semantic-differential scale would not be appropriate for children unless the opposing adjectives are presented in a simplified or graphic form (e.g., ).[4]
[1] The Informed Consent details presented here form all (or at least most of) the first page of the actual questionnaire.
[2] This title applies only to this document: do not include it in your survey. See Appendix A for a sample questionnaire.
[3] This wording may be more culturally appropriate than asking how many children.
[4] Adapted from the psychology department’s web site at the University of California-Davis campus: