COMMUNITY ASSESSEMENT TOOL

Head of the family:

Brgy./Purok: ( ) Married ( ) Unmarried
Sex: ( ) Male ( ) Female Religion:
Age:
Address:

Lot: House:
( ) owned ( ) owned
( ) rented ( ) rented
( ) living ( ) living

Members of the family

Name Age Educational Attainment Occupation

A. Health and Illness Paterns (For children below 7 years old)

Name Age Vaccination
Height Weight BCG DPT OPV Measels Hepa B
(1-3) (1-3) (1-3)

Paraan ng Pagpapasuso
( ) Breastfeeding ( ) Bottle feeding ( ) Mixed
Name Month started Month ended Observation
1. What is the common cause of sickness?
( ) polluted irrigation ( ) dirty surroundings
( ) lack of knowledge about nutrition ( ) negligence
2. In your opinion, what is the cause of the answer in #1 in your community?
_____________________________________________________________________
3. Where do you go if one of the members of your family is sick?
( ) Private clinic/hospital ( ) Health Center
( ) Public clinic/Hospital ( ) Faith healer
4. Why do you bring your family members there when they get sick?
_____________________________________________________________________
5. Does your Health Center have enough capacity to provide good health services?
( ) Yes ( ) No
6. Why yes? Why no?
_____________________________________________________________________
7. What are the services offered by Barangay Health Center?
( ) Free medication / vitamins ( ) Free consultation
( ) Free vaccine ( ) Pregnancy screening
( ) Free extraction of teeth ( ) Diabetes Screening
( ) Evaluation of patients with heart disease ( ) others, please specify:___________
8. Are the medical equipment in the Health Center well used?
( ) Yes ( ) Sometimes ( )No
9. What can you say about the management of your health center?
_____________________________________________________________________
10. Is there a regular health team / worker going to your village?
( ) Yes ( ) None ( ) Sometimes
11. Who provides services to your Barangay Health Center?
( ) Doctor ( ) Midwives ( ) Nutritionist ( ) BHW
( ) Dentist ( ) Nurse ( ) Sanitary Inspector ( ) CHN Volunteers
( ) others, please specify_________
12. Are you given any reminders when there is a designated medical service in your
village?
( ) Yes ( ) No
13. How does the barangay leaders inform / convey when such activities occur and
what are your response in the announcement?
( ) Telephone ( ) Poster ( ) Cellphone ( ) personally
( ) others, please specify:_______
14. Do you attend seminars on health?
( ) Yes ( ) Sometimes ( ) I don’t have time
15. What are the seminars held / conducted in the barangay?
_____________________________________________________________________
16. What is the profession / specialty of people who give seminars?
_____________________________________________________________________
17. Has anyone passed away in your family related to illness / age
_____________________________________________________________________
18. If there is an answer, what did the member of the family experienced and why do
you think this tragedy happened?
_____________________________________________________________________
19. Does your family experience a loss due to pregnancy and childbirth or miscarriage?
( ) Yes ( ) No
20. Why do you think this happened?
_____________________________________________________________________
B. Socio Economic and Cultural Variables
*Social indicators
1. Type of housing:
( ) Wood ( ) Wood and cement ( ) Other, please specify:______
( ) cement ( ) hut / pawid
2. Why did you choose this type of house?
_____________________________________________________________________
3. Is there a church / chapel in your community?
( ) Yes ( ) None
4. Do you attend and how often do you attend church?
_____________________________________________________________________
5. Is there any hospital in your community?
( ) Yes ( ) None
6. How far is your house to the hospital?
_____________________________________________________________________
7. Electrical supply:
( ) Meralco ( ) Generator ( ) None
( ) Batelec ( )Others, please specify:____________
8. How much money do you spend (per month) on electricity?
_____________________________________________________________________
9. Type of transportation present in the community:
( ) Jeep ( ) Pedicab
( ) Ticycle ( ) Others please specify:_________
10. Is there a jeep / tricycle enough to support citizens in transportation?
_____________________________________________________________________
11. Do they pass through the basic infrastructure of the community?
_____________________________________________________________________

12. Type of school present in the community:

( ) Elementary ( ) Secondary ( ) College ( ) None
13. What are the occupation of the members of the family?
( ) Farmer ( ) Driver ( ) other, please specify: ___________
( ) Fisherman ( ) Teacher
14. Who works in your family?
( ) Father ( ) Mother ( ) Child
15. How many family members do not have a good job and why?
_____________________________________________________________________

*Environmental Indicators
1. Type of community where the family is included:
( ) Urban ( ) Rural ( ) Sub-urban
2. Location:
( ) Plains ( ) the mountains ( ) sea side
3. Why did you choose to live here?
_____________________________________________________________________
4. How did you get here?
_____________________________________________________________________
5. How long have you been here?
_____________________________________________________________________
6. Are there any factories near here and what kind of factory is this?
( ) Yes ( ) None
7. What good or evil does it bring?
_____________________________________________________________________
8. Irrigation of water
( ) tank ( ) strait ( ) well
( ) banga ( ) water work system
9. What do you do to make sure that your water is clean?
_____________________________________________________________________
10. Type of toilet available at home:
( ) Flush type ( ) open pit
( ) binubuhusan ( ) others, please specify:__________
11. Is there anyone else who can use your toilet besides your family?
( ) Yes, there is ( ) None
12. Is there drainage / drainage here in your community?
( ) Yes, there is ( ) None
13. Where does it flow?
_____________________________________________________________________
14. Is there a flood whenever it rains?
( ) Yes, there is ( ) Sometimes ( ) None
15. What steps does the management take in solving this problem?
_____________________________________________________________________
16. Waste disposal method
( ) collected ( ) buried ( ) burned ( ) Others
17. Why is this your method of waste disposal?
_____________________________________________________________________
18. Is there a Materials Recovery Facility (MRF) in your community?
( ) Yes, there is ( ) None
19. What does this MRF contribute to your community?
_____________________________________________________________________
20. Does anyone/anything that cause air, water, and land pollution in the community?
( ) Yes, there is ( ) None
21. If any, state the contributors to pollution in your community
_____________________________________________________________________
* Economic Indicator
1. Monthly income:
( ) P1000-P5000 ( )P5000-10000
( ) P11000-15000 ( )P15000-pataas
2. Is this enough for basic needs?
( ) Yes ( ) No
3. Money allocated for food: P_________
4. What is your first purchase of food and does it fit each family member?
_____________________________________________________________________
5. Equipment available:
( ) TV ( ) Radio ( ) DVD player
( ) Refrigerator ( ) Washing Machine ( ) Others, specify:______
6. Number of children that graduated or studying
( ) one ( ) Three to four ( ) None
( ) two ( ) more than four
7. Are the needs of the members of the family whose studying is being met and how
much do you spend for the education of the children?
_____________________________________________________________________

*Cultural Indicators
1. Language
( ) Filipino ( ) English ( ) Others, please specify:_________
2. Dialect
( ) Tagalog ( ) Bisaya ( ) Illongo
( ) others, please specify:_________
3. Do you find it difficult to associate with other people because of other dialects and
why?
_____________________________________________________________________
4. What are some of the occasions that are celebrated here in your community?
_____________________________________________________________________
5. How much money is usually allocated to run the event?
_____________________________________________________________________
6. Do you believe in superstition and why?
( ) Yes ( ) No
7. Do you follow these superstitions, and do you share them with other family
members?
_____________________________________________________________________
8. What religion do you belong?
( ) Catholic ( ) Iglesia ni Kristo ( ) Muslim
( ) Born Again ( ) Jehova’s witness ( ) others, please specify:______
9. Are you active in your religion and why?
_____________________________________________________________________

C. Political and Leadership Pattern

1. Do you think there is enough funding available for health and why?
( ) Yes ( ) No
_____________________________________________________________________
2. Are there any meetings in your village to know your suggestion and needs?
( ) Yes ( ) Sometimes ( ) No
3. Have your grievances been met and how effective are such resolutions?
_____________________________________________________________________
4. Are there many projects that your barangay captain and his officers have come up
with and implemented?
( ) Many ( ) Few ( ) None
5. Do these projects that has been implemented help you live and in what sectors does
this affect your life?
_____________________________________________________________________
6. Do you participate in your captain's projects?
( ) Yes ( ) Sometimes ( ) Never
7. What is the reason why you participate/ or not participate in these projects?
_____________________________________________________________________
8. How many times in a month does your village have free general services?
_____________________________________________________________________
9. Is it the government or the NGO's? What is their purpose in providing free service?
_____________________________________________________________________
10. Do barangay officials provide adequate security to every family in the village?
( ) Yes ( ) Sometimes ( ) No
11. How high is the crime rate in your village?
( ) Large percentage ( ) moderate
( ) Small percentage ( ) I do not know
12. What are the common crimes that occur in your village?
_____________________________________________________________________
13. What steps has the government taken to prevent the recurrence of such crimes?
_____________________________________________________________________

Comments/Suggestions:
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Problems in the barangay:
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