This document contains a student domestic problems inventory rating form. It collects information about the student's gender and family type. It then lists 20 potential domestic problems in 4 categories: financial, health, relationships, and family system. For each problem, the student is asked to rate their level of agreement on a scale from 0-3.

1. STUDENT DOMESTIC PROBLEMS INVENTORY RATING
I - PROFILE:
Gender: Male ( ) Female ( )
Type of Family: Please choose options given below by putting a check (√) marks.
____1. Nuclear
____2. Extended
____3. Matriarchal (Mother-child; Aunt-child; Grandmother-child or Female
Guardian-child)
____4. Patriarchal (Father-child; Uncle-child; Grandfather-child or Male
Guardian-child)
II - THE DOMESTIC PROBLEMS AND ITS DEGREE
Instructions:
1. Please read and understand the question. Your honesty in answering this
questionnaire will lead to the reliability of the data gathered.
2. Do not leave any item unanswered.
3. Indicate your responses by putting a check (√) mark on the score rating in the box
which describe and interpreted as follows:
Score 0 1 2 3
Description Strongly Disagree Disagree Agree Strongly Agree
(SD) (D) (A) (SA)
A. Financial 0-SD 1-D 2-A 3-SA
1. You are bothered because your parents/guardian
cannot sustain family basic needs, school expenses
(tuition) due to low income
2. Your parent/guardian do not have job or lost their job
3. Your family business is begin to have low income or
on bankruptcy
4. No other relatives or members in your family have
work for additional income
5. Your family/parents are in debt and due payments
have been overdue.

2. B. Health 0-SD 1-D 2-A 3-SA
6. It’s been a difficult stage lately due to a death in the
family
7. One of our family members had chronic illness
8. One of our family members is handicap or in need of
consistent special care
9. We are always on stress because of frequent
hospitalization due to recurrent of illness of love ones.
10. There had been a shift of family roles because one of
our family members got sick and still recovering.
C. Relationship 0-SD 1-D 2-A 3-SA
11. There is lack of empathy and disrespect towards
family members, relatives and neighbors due to
misunderstanding.
12. There are frequent occurrences of fights (verbal and
physical) that result into violence within the family
members.
13. Lack of sensitivity or understanding by a child can be
cause for argument in the home due to indiscipline
14. Unfair treatment of one or both parents towards
children can cause enmity and jealousy between
siblings.
15. The relationship between spouses (parent) is not
harmonious, frequent arguments occur.
D. Family System 0-SD 1-D 2-A 3-SA
16. Your feel that your parents/guardian is very lax in
disciplining family members.
17. You feel that your parents/guardian is extremely strict
in discipline.
18. There is unfair distribution of daily household chores
in the family
19. There in unfair sharing of properties or belongings in
the home.
20. There is unfair distribution in providing financial
privileges and implementation of house rules.