Republic of the Philippines

Department of Education
Religion IV-A CALABARZON
Division of Quezon
Our lady of Lourdes Academy Tagkawayan

March 7,2017

Dear Sir/Madam:

We are interested to conduct a survey of the Impact of Climate Change on the rice
fields in Barangay Kinatakutan, Tagkawayan Quezon. This is in partial fulfillment of our
subject Natural Science.

Approval for the farmer to answer the questionnaire

Thank you very much and God bless sincerely

Requested by:
Ella May B. Septimo
Kayela L. Serviano
Mary Grace C. Libunao
Irish Villalon

Noted:

ALVIN D. BUTARDO
Subject teacher
Name Ag Name Ag
: e: : e:
Gend Gend
er: er:

Direction: Please put your answer on the space Direction: Please put your answer on the space
provided after each problem. provided after each problem.

1. The proximity of the 1. The proximity of the

planting area: planting area:
2. No. of years being a 2. No. of years being a
farmer : farmer :
3. The amount of the money spent each 3. The amount of the money spent each
Fertilize Pesticid Fertilize Pesticid
r: es: r: es:
And other And other
equipment: equipment:
4. No. of bucket in every crops. 4. No. of bucket in every crops.
Rainy season: Rainy season:
Summer season: Summer season:

5. No. of planted rice 5. No. of planted rice

annually: annually:

Name: Ag Name: Ag
e: e:
Gender Gender
: :

Direction: Please put your answer on the space Direction: Please put your answer on the space
provided after each problem. provided after each problem.

1. The proximity of the 1. The proximity of the

planting area: planting area:
2. No. of years being a 2. No. of years being a
farmer : farmer :
3. The amount of the money spent each 3. The amount of the money spent each
Fertilize Pesticid Fertilize Pesticid
r: es: r: es:
And other And other
equipment: equipment:
4. No. of bucket in every crops. 4. No. of bucket in every crops.
Rainy season: Rainy season:
Summer season: Summer season:

5. No. of planted rice 5. No. of planted rice

annually: annually: