Questionnaire For Client

Informed Consent Form
Dear participant, good day.

We are postgraduate students from Pusat Pengajian Ilmu Pendidikan, Universiti Sains
Malaysia pursuing Master’s in Counselling. We are currently carrying out a study to assess the
association of Social Support Systems with Anxiety among university students as a part of our
assignment for PLK562 Individual Appraisal.
We would like to invite you to participate in our research study. The description of our
study is as stated below.
Research Title:
The relationship between Social Support Systems and Anxiety among first year
undergraduate USM students.
Purpose of the study:

The study aims to examine the relationship between perceived anxiety and social support
systems among Malaysian university students.
Participation Criteria:
● Malaysian citizen
● You must be a current undergraduate student in USM
● 18 years old and above
If you choose to participate in this study, please answer all the questions as honestly as
possible. By signing this informed consent form, you are indicating that you understand the
nature of the research study and your role in our research and that you agree to participate in the
research voluntarily.
Procedures and Confidentiality

This questionnaire comprises 2 sections and will take no more than 15 minutes to complete.
Section A: Beck Anxiety Inventory (BAI)
Section B: Multidimensional Scale of Perceived Social Support (MSPSS)
All information gathered and provided will remain private and confidential. The
information given will only be reported as group data with no identifying information and only
be used for academic purposes.
Your information will not be disclosed to any unauthorized person and would be
accessible only to group members. Participation in this study is voluntary, you are free to
withdraw with consent and discontinue participation anytime without prejudice. The risk or
potential for distress associated with participation in this project is no greater than that which
would be encountered in everyday life. Your response will be coded numerically in the research
assignment for the research interpretation. Your data, access to which is only between the team
members assigned the task, will be deleted after the completion of the study. Your cooperation
would be greatly appreciated. If you have any questions regarding the study, please feel free to
contact [email protected].
Participation Benefits:
Your participation will help to increase the current knowledge on the relationship between
perceived anxiety and social support systems among Malaysian university students.
Withdrawal:
You may withdraw from participating at any time while answering. No action can or will
be taken against you. To withdraw your participation, just exit from the Google Form and
whatever responses you have given will not be saved.
Concerns:
Should you have any questions/concerns regarding this study, feel free to direct them to the
researchers at the contacts given below.
Prepared and researched by,

Chew Yong Peng ([email protected])
Ong Zi-Huang ([email protected])
Zhao Yuan Zhe ([email protected])
Yang Fan Si Jin ([email protected])
Thank you.
Beck Anxiety Inventory (BAI)
Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have
been bothered by that symptom during the past month, including today, by circling the number in the corresponding space
in the column next to each symptom.
Mildly, but it Moderately – it Severely – it

Not at all didn’t bother wasn’t pleasant bothered me
me much at times a lot
Numbness or tingling 0 1 2 3
Feeling hot 0 1 2 3
Wobbliness in legs 0 1 2 3
Unable to relax 0 1 2 3
Fear of worst happening 0 1 2 3
Dizzy or lightheaded 0 1 2 3
Heart pounding / racing 0 1 2 3
Unsteady 0 1 2 3
Terrified or afraid 0 1 2 3
Nervous 0 1 2 3
Feeling of choking 0 1 2 3
Hands trembling 0 1 2 3
Shaky / unsteady 0 1 2 3
Fear of losing control 0 1 2 3
Difficulty in breathing 0 1 2 3
Fear of dying 0 1 2 3
Scared 0 1 2 3
Indigestion 0 1 2 3
Faint / lightheaded 0 1 2 3
Face flushed 0 1 2 3
Hot / cold sweats 0 1 2 3
References: Beck, A.T., Epstein, N., Brown, G., & Steer, R.A. (1988). An inventory for measuring clinical anxiety: Psychometric
properties. Journal of Consulting and Clinical Psychology, 56, 893-897.
Multidimensional Scale of Perceived Social Support
Instructions: We are interested in how you feel about the following statements. Read each statement
carefully. Indicate how you feel about each statement.
Circle the “1” if you Very Strongly Disagree

Circle the “2” if you Strongly Disagree
Circle the “3” if you Mildly Disagree
Circle the “4” if you are Neutral
Circle the “5” if you Mildly Agree
Circle the “6” if you Strongly Agree
Circle the “7” if you Very Strongly Agree
Very Very
Strongly Strongly Mildly Mildly Strongly Strongly
Disagree Disagree Disagree Neutral Agree Agree Agree
1. There is a special person who

is around when I am in need. 1 2 3 4 5 6 7
2. There is a special person with

whom I can share joys and sorrows. 1 2 3 4 5 6 7
3. My family really tries to help me. 1 2 3 4 5 6 7
4. I get the emotional help & support

I need from my family. 1 2 3 4 5 6 7
5. I have a special person who is

a real source of comfort to me. 1 2 3 4 5 6 7
6. My friends really try to help me. 1 2 3 4 5 6 7
7. I can count on my friends when

things go wrong. 1 2 3 4 5 6 7
8. I can talk about my problems with

my family. 1 2 3 4 5 6 7
9. I have friends with whom I can

share my joys and sorrows. 1 2 3 4 5 6 7
10. There is a special person in my

life who cares about my feelings. 1 2 3 4 5 6 7
11. My family is willing to help me

make decisions. 1 2 3 4 5 6 7
12. I can talk about my problems with

my friends. 1 2 3 4 5 6 7
Scale Reference:
Zimet GD, Dahlem NW, Zimet SG, Farley GK. The Multidimensional Scale of Perceived Social Support.
Journal of Personality Assessment 1988;52:30-41.

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Informed Consent Form

Dear participant, good day.

Purpose of the study:

Procedures and Confidentiality

Prepared and researched by,

Mildly, but it Moderately – it Severely – it

Fear of worst happening 0 1 2 3

Heart pounding / racing 0 1 2 3

Fear of losing control 0 1 2 3

Hot / cold sweats 0 1 2 3

Circle the “1” if you Very Strongly Disagree

1. There is a special person who

2. There is a special person with

3. My family really tries to help me. 1 2 3 4 5 6 7

4. I get the emotional help & support

5. I have a special person who is

6. My friends really try to help me. 1 2 3 4 5 6 7

7. I can count on my friends when

8. I can talk about my problems with

9. I have friends with whom I can

10. There is a special person in my

11. My family is willing to help me

12. I can talk about my problems with

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