Form 1: Household Survey Form

Instructions Barangay:
1.1 Fill-in the blanks with the appropriate marks for items 1,2,3,4,10,11,12 Municipality:
(/) - With/Yes
(X) - Without/No

1.2 For other items, fill-in with corresponding count

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Clean Water, Energy, and Sanitation for All
1 Is there an access to clean and potable
water?
Is the source of drinking water less
2 than 250 meters away from your
house?

3 Do you have an access to a sanitary

toilet?*
4 Is there any electricity in the dwelling
place?
Inclusive and Equitable Education
How many household members (6-11
5 years old)are not attending
elementary?

How many household members (12-15

6 taong gulang)are not attending high
school?
Good Health and Well-being

How many household members (0-5

7
years old) are malnourished?

How many household members (0-5

8 years old) did not received any
vaccine?

How many household members died

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due to pregnancy-related causes?
 Do you own/rent the house and lot
10 where you are residing?

If family doesn't own and rent the house/lot,

11 do you have the consent of the owner to
stay in the house/lot?
Disaster Resilient Community
12 Do you have an emergency balde or
emergency kit?

1.3 Use additional copy of Form 1 Household Survey Form if necessary

1.4 Sum-up the values of cells answered with numerical figures and find the total
-To find the total for items 1,2,3,4,10,11,12 count the total number of 'X'
Name and Signature of Barangay Chairman Name and Signature of Data Collector
Form 1: Household Survey Form
Panuto Barangay:
1.1 Punan ang patlang ng naangkop ng sagot para sa aytem ika 1,2,3,4,10,11,12 Municipality:
(/) - Meron/Oo
(X) - Wala/Hindi

1.2 Sa ibang aytem, punan ng wastong bilang

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Clean Water, Energy, and Sanitation for All
May mapagkukunan ng malinis at
1
naiinom na tubig?*

Ang pinagkukunan ba ng tubig ay

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hindi lumalayo sa 250 metro?
3 May maayos na palikuran?*

4 May kuryente ba sa inyong

tinitirahan?*
Inclusive and Equitable Education
Ilang miyembro ng pamilya (6-11
5 taong gulang) ang hindi pumapasok sa
elementarya?

Ilang miyembro ng pamilya (12-15

6 taong gulang) ang hindi pumapasok sa
hayskul?
Good Health and Well-being
Ilang miyembro ng pamilya (0-5 taong
7
gulang) ang malnourished?

Ilang miyembro ng pamilya (0-5 taong

8
gulang) ang hindi pa nababakunahan?

Ilang miyembro ng pamilya ang

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namatay dahil sa pagbubuntis?
Nakatira sa pagmamay-aring tahanan/
10 umuupa?
 Kung hindi pagmamay-ari o nirerentahan ang
tahanan, may pahintulot ba ng may-ari ng bahay
11 ang pagtira sa kasalukuyang tinirhang bahay at
lupa?
Disaster Resilient Community
12 May emergency balde o emergency
kit?

1.3 Gumamit ng karagdagang kopya ng Form 1 Household Survey Form kung kinakailangan
1.4 I-total ang mga nakuhang datos na naayon sa bawat bilang
-Para sa aytem ika 1,2,3,4,10,11,12 total na bilang ng 'X'
Pangalan at Lagda ng Punong-Barangay Pangalan at Lagda ng Tagangalap ng Datos
Form 2: Data Aggregation Form Municipality of:
Municipality

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Transparency and Accountability

1 Has the barangay posted all the six financial documents

at the barangay hall that is visible to the public?*
2 Is the municipality compliant with the Full Disclosure
Policy?
3 What is the average growth in local revenues?
4 COA Opinion?
Clean Water, Energy, and Sanitation for All
5 How many HHs without access to potable water?
6 How many HHs without sanitary toilet?
7 How many HHs without electricity?
Inclusive and Equitable Education
How many children 6-11 years old are not attending
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elementary school (for SY 2015-2016)?

9 How many children 12-15 years old are not attending

high school (for SY 2015-2016)?
Good Health and Well-being
10 How many children aged 0-5 are malnourished?
11 How many children aged 0-5 have not received any
vaccine?
12 How many women died due to pregnancy related
causes?
13 How many HHs are living in makeshift housing?
14 How many HHs are informal settlers?
Disaster Resilient Community
15 How many HHs without emergency kit (emergency
'balde/emergency 'go bag')?
16 Are there signs/directions going to the evacuation
center?
17 How many items are not yet obtained in Operation
Listo checklist?
More Business and Investments
18 How long are unpaved brgy roads (in meters)?
19 How long are unpaved municipal roads (in kms) ?

20 How many companies/enterprises were issued with

permit(new) beyond 5 days after application?

21 How many companies/enterprises were issued with

permit (renewal) beyond 1 day after application?
Peaceful, Orderly, and Just Community

22 How many complaints are settled through Lupong

Tagapamayapa?
23 Has the barangay submitted its VAWC report?
Clean and Livable Environment

24 Is there an access to material recovery facility in the

barangay? (e.g., solid waste storage and recycling area)
25 Is the barangay practicing segregation?
26 Is there an access to sanitary landfill?
27 Is there a waste collection system?
Name and Signature of Municipal Mayor Name and Signature of MLGOO
Form 2: Data Aggregation Form City of:
City

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Transparency and Accountability

1 Has the barangay posted all the six financial documents at the
barangay hall that is visible to the public?*
2 Is the City compliant with the Full Disclosure Policy?
3 What is the average growth in local revenues
4 COA Opinion?
Clean Water, Energy, and Sanitation for All
5 How many HHs without access to potable water?
6 How many HHs without sanitary toilet?
7 How many HHs without electricity?
Inclusive and Equitable Education

8 How many children 6-11 years old are not attending

elementary school (for SY 2015-2016)?

9 How many children 12-15 years old are not attending high
school (for SY 2015-2016)?
Good Health and Well-being
10 How many children aged 0-5 are malnourished?

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How many children aged 0-5 have not received any vaccine?
12 How many women died due to pregnancy related causes?
13 How many HHs are living in makeshift housing?
14 How many HHs are informal settlers?
Disaster Resilient Community

15 How many HHs without emergency kit (emergency

'balde/emergency 'go bag')?
16 Are there signs/directions going to the evacuation center?

17 How many items are not yet obtained in Operation Listo

checklist?
More Business and Investments
18 How long are unpaved brgy roads (in meters)?
19 How long are unpaved cityl roads (in kms) ?

20 How many companies/enterprises were issued with

permit(new) beyond 5 days after application?

21 How many companies/enterprises were issued with permit

(renewal) beyond 1 day after application?
22 How many new businesses registered?
23 How many businesses survived for at least three years?
24 Is there a transport management plan?
Peaceful, Orderly, and Just Community

25 How many complaints are setteld through Lupong

Tagapamayapa?
26 Has the barangay submitted its VAWC report?

27 How many obstructions can be seen on sidewalks and other

public places?
Clean and Livable Environment

28 Is there an access to material recovery facility in the

barangay? (e.g., solid waste storage and recycling area)
29 Is the barangay practicing segregation at source?
30 Is there an access to sanitary landfill?
31 Is there a waste collection system?
32 Is there a tree park in the city center or in any strategic area?
Name and Signature of City Mayor Name and Signature of CLGOO
Form 2: Data Aggregation Form Province of:
Province

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Transparency and Accountability
1 Compliance with Full Disclosure Policy
2 No. of brgys that did not post all the six financial documents at the barangay hall
4 COA Opinion
5 Local Revenue Growth
Clean Water, Energy, and Sanitation for All
6 No. of HHs without access to potable water
7 No. HHs without sanitary toilet
8 No. of HHs without electricity
Inclusive and Equitable Education

9 No. of children 6-11 years old who are not attending elementary school (for SY 2015-
2016)

10 No. of children 12-15 years old who are not attending secondary school (for SY 2015-
2016)
Good Health and Well-being
11 No. of children aged 0-5 who are malnourished
12 No. of children that have not received any vaccine
13 No. of women who died due to pregnancy related causes
14 No. of HHs living in makeshift housing
15 No. of informal settlers per HH
Disaster Resilient Community
16 No. of items not yet obtained in the 'Operation Listo' checklist
17 No. of HHs without 'emergency balde'
18 No. of barangays without signs/directions going to the evacuation center
More Business and Investments
19 Total length of unpaved barangay roads (in meters)
20 Length of unpaved municipal/city roads (in km)
21 Number of businesses not issued with permit (new) within 5 days
22 Number of businesses not issued with permit (renewal) within 1 day
23 Number of new businesses registered
24 Number of businesses survived for at least three years (based on renewal of permits)
25 Presence of transport management plan
Peaceful, Orderly, and Just Community
26 No. of complaints settled through Lupong Tagapamayapa
27 No. of VAWC reports submitted
28 No of Obstructions on sidewalks and other public places
Clean and Livable Environment
29 Number of barangays without access to material recovery facility
30 No. barangays not practicing segregation in the barangay hall
31 Access to sanitary landfill
32 Presence of waste collection system
33 Presence of tree parks/open space in city center or strategic area

Name and Signature of Governor Name and Signature of DILG-PD