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 Consent1
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 ____@pathseminary.org
For further information, including a copy of the results of this study, please contact:
_______________________ [the researcher]
_______________________ [the researchers 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.

1 The Informed Consent details presented here form all (or at least most of) the first page of the
actual questionnaire.

Common Demographic Variables2

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 age

2534 years of age
3544 years of age
4554 years of age
5564 years of age
6574 years of age
75 years of age or older

The tick-response option immediately above would be relevant for a 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)...........

1213 years of age

1415 years of age
1617 years of age
1819 years of age
2021 years of age
2223 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]

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.

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

How many years have you been a member of this church? ___ years

[fill-in response option]

What is your highest educational qualification-accomplishment? __________

What is your highest educational qualificationaccomplishment? (tick one of the choices at right)

[fill-in response option]

[fill-in response option]

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 associates degree
Bachelors degree
Postgraduate diploma or BA Honours
Masters degree
Professional degree
Doctorate degree

The categories in the tick-response option above must be (1) inclusive so everyone can
answer, (2) adjusted to fit the sample being surveyed, and (3) adjusted to reflect the local
or national terminology used (e.g., la matrise in Francophone educational systems) . This
adjustment in terminology must go beyond language translation because Africas
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?......................

(tick only one of the choices at right)

Pastor
Youth leader
Evangelist
Missionary
Mens ministries leader
Other: ___________________________

The categories above in the tick-response option must (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

What is your current annual income? ___________
What is your current annual income? )
(tick only one of the choices at right)

[fill-in response option]

[fill-in response option]

Less than $20,000

$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 above in 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., What was 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.

First statement to be judged-evaluated..........................

Second statement to be judged-evaluated.....................
Third statement to be judged-evaluated........................

Strongly
Agree

Agree

Uncertain
or Neutral

Disagree

Strongly
Disagree

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 tick next to one of the words indicates a very strong feeling:.....Decisive Indecisive
A tick near 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. There are no right or wrong answers.
Strong
Decisive
Good
Cheap
Active
Lazy

Weak
Indecisive
Bad
Expensive
Passive
Industrious

A semantic differential scale requires respondents who are intelligent, cooperative, and
comfortable with the 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

4 Adapted from the psychology departments web site at the University of California-Davis
campus: http://psychology.ucdavis.edu/sommerb/sommerdemo/scaling/semdiff.htm