FAR EASTERN UNIVERSITY Institute of Nursing Community Health Survey Tool Head of the Family:_____________________________ (kinikilalang puno ng pamilya)

Com!lete Addre"": __________________________________________ (Tirahan) $en%th of Re"iden&y:_________________________________________ (Tagal ng paninirahan sa lugar) (la&e of )ri%in: _________________________________ (Lugar na pinagmulan) Ethni& +a&,%round: ______________________________ (Etnikong grupo na kinabibilangan) (rimary *iale&t S!o,en: __________________________ (Pangunahing Dialektong ginagamit) C)--UNITY AS A (E)($E Family Stru&ture. Chara&teri"ti&" and *ynami&" No (Blg ) Name of !ousehol" #ember(s) (Pangalan ng myembro ng pamilya) $elationship to the hea" of the family (kaugnayan sa puno ng pamilya) E"u+ation (E"ukasyon) !ighest E"u+ational E"u+ational %tatus )ttainment ()ntas ng Pinaka-mataas E"ukasyon) na )ntas ng E"ukasyong natapos ,++upation (!anap Buhay) Pla+e (Lugar) Type (-ri) )&&u!ational Statu" ('alagayan ng Trabaho) Control No __________ No of Family#familie" :___________ (Bilang ng Pamilya) Surveyed 'y :____________________________ (Pangalan ng Nag-survey) *ate :____________________ (Petsa)

%e& ('asarian)

Date of Birth (mo ( "ay( yr ) (kapanganakan)

)ge (E"a")

*ivil %tatus (Esta"o %ibil)

$eligion (relihi -yon)

$E/EN*:

# . male 0 - female

% . %ingle # . #arrie" 1 . 1i"o2e" *L . *ommon La2 %ep . %eparate"

*- *atholi+ P . Protestant %) . 3th Day )"ventist IN* . Iglesia ni *risto 41 . 4ehova5s 1itness

E/ . Elementary /ra"uate E- . Elementary -n"ergra" !/ . !igh %+hool /ra" !- - !igh %+hool -n"ergra" *- . *ollege un"ergra" 6 - 6o+ational

N0 . No 0ormal E"u+ation P% . Presently %tu"ying %% . %toppe" %tu"ying * . *ollege /ra"

E . Employe" - . -nemploye"

C)--UNITY AS A S)CIA$ SYSTEA E&onomi& A"!e&t 78 *ombine" #onthly family in+ome (Bu2anang kita ng pamilya) ( ) P7(::: an" belo2 ( ) P7(::7 . P;(::: ( ) P;(::7 . P7:(::: ( ) P7:(::7 . P7;(::: ( ) P7;(::7 . P<:(::: ( ) P<:(::7 . P<;(::: ( ) P<;(::7 . P8:(::: ( ) P8:(::7 an" above 79 *ommunity Program ()no ang mga alam na programa sa komuni"a") ==== a2are ===== una2are

7> ,ther sour+es of In+ome (livelihoo") (#ayroon pa bang ibang pinagkukunan ng kabuhayan?) ( ) @es ( ) No If yes( 2hat? (kung mayroon( ano ito?) ( ) sari-sari store ( ) poultry raising ( ) livesto+k raising ( ) +raft making ( ) ,thers Cpls spe+ifyD================

( ) pea+e an" or"er ( ) fumigation ( ) +urfe2 ( ) tapat ko linis ko ( ) sportfest ( ) others( pls spe+ify ============== 7A Pre"ominant ,rganiBations in the +ommunity ('ilalang samahan sa komuni"a") ( ) Barangay *oun+il ( ) %angguniang 'abataan ( ) *ouples for *hrist ( ) %eniors *itiBens *lub ( ) other( pls spe+ify ========================= ===== member ===== non - member

7> #onthly family e&pen"iture (Bu2anang gastusin ng pamilya)

( ) P7(::: an" belo2 ( ) P7(::7 . P;(::: ( ) P;(::7 . P7:(::: ( ) P7:(::7 . P7;(::: ( ) P7;(::7 . P<:(::: ( ) P<:(::7 . P<;(::: ( ) P<;(::7 . P8:(::: ( ) P8:(::7 an" above

<: Tra"itions +elebrate"E observe" in the +ommunity (Tra"isyong i"inaraosE ipinag"iri2ang sa komuni"a") ( ) 0iesta ( ) !oly 1eek ( ) others( pls spe+ify ============================== C Environmental A"!e&t <7 Lan" ,2nership (Pagmamay-ari ng lupang tinitirahan)

7; Priority E&pen"iture( rank it 7 . 3 (7 is the highestF 3 is the lo2est)

==== foo" (pagkain) ==== house rental (upa sa bahay) ==== ele+tri+ bill (bayarin sa kuryente) ==== 2ater bill (bayarin sa tubig) ==== health (kalusugan) ==== e"u+ation (e"ukasyon) ==== +lothing ("amit)

7G $esour+es allotte" for health +are

(Nakalaang pon"o para sa kalusugan) ( ) @es ( ) No If yes( from 2here? (kung oo( galing saan?) ( ) !ealth Insuran+e ( ) %%%E/%I% ( ) Phil !ealth ( ) savings ( ) others( please spe+ify ================ + (oliti&al # $eader"hi! A"!e&t 73 $e+ogniBe" lea"ers in the +ommunity (unang taong kinukunsulta at kinikilalang pinuno ng komuni"a") ( ) o2ne" ( ) rente" ( ) lease to o2n ( ) rent free << !ouse ,2nership (pagmamay-ari ng bahay na tinitirhan) ( ) o2ne" ( ) rente" ( ) lease to o2n ( ) rent free

<8 Type of #aterials -se" for house (-ri ng #ateryales ng bahay) ( ) light <> 6entilation ( ) 2ell ventilate" ( ) fair ( ) poorly ventilate" (reHuirementI opening 7:J of floor area) ( ) strong ( ) mi&e" ( ) makeshift (barong barong)

( ) Barangay ,ffi+ials ( ) religious lea"ers ( ) el"ers ( ) Non- government organiBations ( ) others( pls spe+ify ============

<; Lighting . fa+ilities

( ) ele+tri+ity ( ) kerosene ( ) +an"les ( ) others( pls spe+ify =================== ==== a"eHuate ==== ina"eHuate

88 %torage of "rinking 2ater (Imbakan ng inuming tubig) ( ) 4ar (banga) ( ) bottles ( ) 2ater tank ===== +overe" ( ) plasti+Eglass +ontainer ( ) "rum ( ) 2ater "ispenser ===== un+overe"

<G E&+reta Disposal ( -ri ng Palikuran)

( ) pail system ( ) flush type ( ) bore" hole latrine ( ) overhung latrine ( ) open pit privy ( ) )ntipolo type ( ) +lose" pit privy ( ) 2ater . seale" latrine

8> #etho" +ommonly use" in sanitiBing 2ater (Paraang ginagamit upang mapanatiling malinis ang inuming tubig) ( ) boiling (pagpapakulo) ( ) filtration (pagsasala ( ) se"imentation (pagpapalatak) ( ) others( pls spe+ify ========================== 8; Domesti+ animals upkeep ("ogs an" +ats only)

<3 ,2nership of Toilet 0a+ility (pagmamay-ari ng palikuran)

( ) private (sariling gamit) ( ) share" (may kahati sa gamit) ( ) publi+ (gamit pambayan) <9 %e2erage %ystem in the +ommunity ( -ri ng kanal sa komuni"a") ( ) blin" "rainage ( ) open "rainage ( ) none

'in" (-ri)

Number (bilang)

Pla+e kept (pinaglalagyan )

6a++ination (Bakuna sa hayop) 1ith (mayroon) 1ithout (2ala)

<A *on"ition ( kalagayan ng "aloy ng tubig sa kanal)

8G Present of ve+tors an" ro"ents (pagkakaroon ng peste sa bahay) ( ) free flo2ing ( ) stagnant ( ) flies (langa2) ( ) termites (anay) ( ) rats ("aga) ( ) roa+hes (ipis) ( ) mosHuitoes ( lamok) ( ) others( pls spe+ify ========================== 83 Presen+e of bree"ing sites of ve+tors ( pagkakaroon ng lugar na pinamamahayan ng mga peste) ==== 2ith ==== 2ithout if 2ith( pls spe+ify lo+ation ======================= 89 1ays of +ontrolling ve+tors (Paraang ginaga2a upang mapuksa ang mga peste sa bahay) ( ) fumigation (pag-papa-usok) ( ) inse+ti+i"es ( pmatay insekto) ( ) fly traps ( ) mouse traps ( ) s+reens on "oors an" 2in"o2s ( ) others( pls spe+ify =====================================

8: Type of 2aste "isposal use" (-ri ng pagtatapon ng basura)

( ) animal fee" ( ) +omposting ( ) open "umping ( ) burial pit ( ) burning ( ) garbage +olle+tion (DP%) ( ) others( pls spe+ify ========================== 87 *ontainer use" for garbage ( ) garbage bag ==== +overe" ( ) 2aste basket ( ) sa+k ( ) none ==== un+overe"

8< %our+e of "rinking 2ater (pinanggagalingan ng inuming tubig)

( ) +ommer+ially prepare" 2ater ( ) lo+al 2ater system ( ) "eep 2ell ( ) rain 2ater

( ) artesian 2ell * Health A"!e&t

( ) streams( rivers or spring

8A *ommunity health programs (programang pangkalusugan) ( ) 0ree +onsultation (libreng konsulta) ( ( ( ( ( ) ImmuniBation (libreng Bakuna) ) 0amily Planning (Programa sa pagpapaplano ng pamilya) ) Pre-natal *he+k up (programa para sa buntis) ) 2ell-baby +lini+ (konsulta para sa mga sanggol at bata) ) ,thers (Pls %pe+ify) ============================

)2are -tiliBes ()lam) (nagkukunsulta) ====== ======= ====== ====== ====== ====== ====== ======= ======= ======= ======= =======

>8 #e"i+ations taken "uring illness (/amot na iniinom) ( ) pres+ribe" ( ) herbal ( ) over the +ounter

( ) others ( Pls %pe+ify) =====================

>> #etho" of 0amily Planning (Pagpaplano ng pamilya)

Name

)ge

)++eptor

Non)++eptor

>: 0oo" usually eaten (#a"alas ng kinakain)

( ) 0ish ( ) #eat ( ) 6egetable ( ) #i&e"

) Natural ( ) rhythm

( ) +ervi+al mu+us metho"

( ) 2ith"ra2al

>7 0oo" storage pra+ti+es (Pangangalaga sa pagkain)

( ) refrigerator ==== +overe" ( ) table ( ) basket ====-n+overe" ( ) others ==============

( ) Basal bo"y temperature B )rtifi+ial +ontra+eptives ( ) +on"oms ( ) I-D * Permanent ( ) vase+tomy ( ) tubal ligation

( ) others (spe+ify) ============ ( ) pills ( ) others ==========

>< 0irst person +onsulte" in times of illness (-nang taong kinukunsulta tu2ing
( ) "o+tor ( ) nurse ( ) B!1 ( ) albularyo ( ) faith healer ( ) hilot may nagkakasakit) ( ) mi"2ife ( ) relatives ( ) family ( ) others (pls spe+ify)==============

For item" 01 2 03: An"4er only if a!!li&a'le

o 05 and 06 2 If there are &hildren 7 2 89 month" in the family o 03 2 if there are &hildren 7 2 3: month" ;7 2 6 yr"< in the family o 05 2 if there i" a !re%nant mem'er of the family

01 Infant Feedin% (ro%ram ; < +rea"t -il, ; < Commer&ially (re!ared -il, Commer&ially (re!ared:: _____ Conden"ed -il, _____ (o4dered -il, _____ Eva!orated -il, _____ )ther" ;!lea"e "!e&ify< ________________ ; < -i=ed

05 -aternal Care ;(an%an%ala%a "a m%a 'unti"< Name ;(an%anlan< No of (re%nan& y A%e of /e"tation ;+ilan% n% 'u4an n% !a%'u'unti"< E=!e&ted *ate of *elivery ;Inaa"ahan% !et"a n% !an%an%ana,< (reNatal Che&, > U! 4ith 4ithout Tetanu" To=oid Immuni?ation 4ith 4ithout

06 Immuni?ation Statu" of Tar%et A%e /rou! ;7 2 89 month"< Name A%e in -o" +C/ 8 *(T 9 : 8 )(V 9 : 8 He!atiti" + 9 : A-V in&om!lete Remar," &om!lete Fully Immuni?ed

03 Nutritional Statu" for Children ;7 2 3: month"< Name ;(an%alan< *ate of @ei%hin% ;(et"a n% (a%tim'an%< *ate of +irth ;Aa!an%ana,an< A%e ; in month"< ;Edad< @ei%ht ;+i%at< Remar,"

0B -or'idity Name ;(an%alan< Intervention ;-edi&ation< @ith @ithout

A%e ;Edad<

Se= ;+i%at<

>EN*>