Western Mindanao State University COLLEGE OF NURSING COMMUNITY SURVEY TOOL INTRODUCTION This tool serves as a guide for

interviewers in gathering data from and about the families that constitute the community. The information gathered will serve as basis in determining community s health status and awareness of health threats and health deficits. DIRECTION. A. Fill in the correct information as indicated. B. Puts check (/) in te bracke if item alongside is present in the community REMINDER. Greeting and self-introduction should be done.

HOUSEHOLD # ________________________ INTERVIEWER _________________________ I.

DATE OF INTERVIEW _____________

COMMUNITY CORE NAME:_____________________________________________________ ADDRESS/BARANGAY:__________________________________________ SEX: ( )Male ( )Female CIVIL STATUS : ( )Single ( )Married ( )Widow ( )Separated RELIGION: ( )Roman Catholic ( )Islam ( )Protestant Others, specify _____________________________________ DIALECT ( )Tausug ( )Tagalog ( )Ilokano ( )Chavacano ( )Bisaya ( )Others, specify: ______________________ FAMIALY STRUCTURE ( )Nuclear ( ) Kin Network ( )Extended Others, specify _______________ ETHNICITY ( )Tagalog ( )Tausug ( )Zamboangueno ( )Bisaya ( )Others, specify ___________________ AGE GROUP