Date_______________________________ Province/City___________________________

Interviewer__________________________ Municipality___________________________
Church_____________________________ Barangay______________________________

PHILIPPINE CHURCH AND BARANGAY BASED

MONITORING SYSTEM FOR TRACKING COMMUNITY NEEDS FOR LONG TERM SUSTAINABILITY

Name of Household_______________________________________________Age_________ Sex_________ Status: Married _________Single _________Widowed _________ Separated _________
Occupation _____________________________________________Wage ___________ / Daily_____________ / Weekly Status of Employment: Self Employed ___________ Employed__________
Name of Spouse _______________________________________ Age ________ Sex ________ Occupation _________________ No. of Children: Total ________ Male ________Female _________
Address ____________________________________________________________________________________________ Other Dependents No.: Total ________ Male ________Female _________
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Fill-up Directions
1. Check the column that applies to your answer: (y=yes); (n=no); blank (important details)
2. Submit accomplished form submit to Church Monitoring Team (CMT) to Barangay Monitoring Team (BMT) for Barangay Budget Allocation every semester SM1: January 10 SM2: June 1 of the year.

Note: This form shall be used for three (3) years.

2 0 1 1 2 0 1 2 2 0 1 3
BASIC NEEDS INDICATORS S 1 S 2 S 1 S 2 S 1 S 2
y n y n y n y n y n y n
A.SURVIVAL 1. Access to food 3 times a day

1. Food and Nutrition 2. No under malnourished within family

3. No family member hospitalized within
the month
4. Infants exclusively breastfed for at least
4 months
2. Health 5. Deliveries attended by trained personnel
6. 0-1 year old infants fully immunized
7. Pregnant women given maternal care
8. Access to ambulance in case of
emergency.
9. No deaths in the family due to
preventable causes within one year
10. Couples with access to family planning
11. Couples practicing family planning in
the last 6 months
12. No family member has sickness in a
month
3. Water and Sanitation 13. Family access to comfort room
14. Access to clean drinking water
4. Clothing 15. Family members with basic clothing
(at least 7 sets of external and internal
clothing)
 2 0 1 1 2 0 1 2 2 0 1 3
BASIC NEEDS INDICATORS S 1 S 2 S 1 S 2 S 1 S 2
y n y n y n y n y n y n
16. Housing owned
B.SECURITY
5. Shelter 17. Housing durable for at least 5 years
6. Peace and Order / 18. Family members safe from crimes
Public Safety against person (murder, rape, abuse)
19. Family members safe from crimes
against poverty(robbery, theft)
20. Family members safe from natural
disaster (landslide, flood)
21. Immediate response of police or
Barangay Tanod in case of emergencies.
7. Income and 22. Head of Family employed
Livelihood 23. Other members of the family 18 years
and above employed
24. Family with income sufficient for
daily existence
25. Roads accessible farm to market
C. ENABLING 26. Children 6-12 years old in elementary
8. Basic Education and school
Literacy 27.Children 13-16 years old in high
school
28. Children 16-20 above are in college
9. People’s 29. Family members involved in at least
Participation in legitimate people’s organization / assn.
Community for community development
Development 30. All Family members able to vote at
elections
10. Family Care / 31. No children below 15 years old
Psychosocial engaged in hazardous occupation
32. No incidence of domestic violence
33. No children below 7 yrs. old left
unattended
11. Debt from 34. Up to present
Micro financing 35. Before but now fully paid
12. Assignment of 36. Husband
Household Chore 37.Children
13. Saving Ability 38. Have a bank account and save
14. Improvements in 39. Able to buy furniture, tv set, etc.
Standard of Living 40. Able to go to mall, eat out and buy
new clothes