De La Salle Santiago Zobel

Ayala Alabang, Muntinlupa City

FAMILY BACKGROUND QUESTIONNAIRE

Date: ____/____/_____
(Day) (Month) (Year)

I – Family Profile

1. Name:______________________________ 1. Name:______________________________

2. Age:___________ 2. Age:__________

3. Gender: Male [ ] Female [ ] 3. Gender: Male [ ] Female [ ]

4. Birth Date: ____/____/____ 4. Birth Date: ____/____/____
(Day) (Month) (Year) (Day) (Month) (Year)

5. Occupation: _________________________ 5. Occupation: _________________________

6. Highest level of Education: 6. Highest level of Education:

[ ] Primary school or less [ ] Primary school or less

[ ] High School [ ] High School
[ ] College [ ] College

6. Child/Children’s Name and Age:

_____________________________[______] ______________________________[______]

_____________________________[______] ______________________________[______]

_____________________________[______] ______________________________[______]

_____________________________[______] ______________________________[______]

7. Does your child/children experience any of the following problems:

A chronic illness e.g asthma, eczema? YES [ ] NO [ ]

A physical disability? YES [ ] NO [ ]

A developmental delay? YES [ ] NO [ ]

If YES to any of the above, please provide details:

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 II – Present Work

1. Are you working outside the home? 1. Are you working outside the home?

[ ] Yes, Full time [ ] Yes, Full time

[ ] Yes, Part time [ ] Yes, Part time
[ ] Not working [ ] Not working

2. Why do you work? 2. Why do you work?

[ ]My family needs my income [ ]My family needs my income

[ ]To keep a foot in the door in my career [ ]To keep a foot in the door in my career
Other, please specify: ____________________ Other, please specify: ____________________

2. How much is the salary? ___________ 3. How much is the salary? ____________

3. Monthly/ Daily Budget: __________________

4. Monthly/ Daily Expenses:__________________

III – Reflection

1. What is the hardest part of being a working parent? ( Ano po yung pinakamahirap na punto sa isang
magulang na naghahanap-buhay?)

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2. Paano nyo tinatawid o kinakaya ang pang araw-araw na buhay?

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3. Kung bibigyan kayo ng pagkakataon na maiparating sa ating gobyerno ang inyong mga hinaing o
suliranin, ano po ito?

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4. Gaano po kahalaga ang inyong pananampalataya sa Dyos sa kabila ng lahat na inyong nararanasan sa
buhay?

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