Columns Description

A Write the number of HH as you go on with the profiling, disregard any existing number of HH in the area. Your first house will be your number "1". Put the same
household number to all the members of the household.
B Use Arabic numeral for each person in a continuous pattern from number "1" and so on. Do not skip any row in encoding.
C Use upper case for the first letter of the name only. (Surname, First Name Middle Name) e.g., Dela Cruz, Juan Bonifacio
D Write the relationship to HH head in word such as wife, son or daughter corresponding to the number in the collecting tool. Upper case for the 1st letter of the
word only
E Just fill in birthdates in mm/dd/yyyy manner. Do not fill in the age cell, it will automatically compute age in real time.
F Age will be automatically generated/computed when date of birth is filled out.
G Write the word "Male" or "Female" in the column
H Write the occupation or source of income in word, Upper case for the 1st letter of the word only
I Write the "average monthly income" of individual with occupation and/or source of income.
J Write specific religion given such as: Catholic, Iglesia ni Cristo, Protestant, Seventh Day, etc.
K Write the specific educational attainment in word such as "Grade 1, Grade 2" etc., Upper case for the 1st letter of the word only
L Write the complete PhilHealth number for each individual
M Write the word "Yes" or "No"
N Write the word "Yes" or "No"
O Write the specific disability
P Write the specific existing disease such as hypertension, diabetes, tuberculosis, mental illness etc.

Write Roman Numeral corresponding to the level of water source such I, II, III. Definition of terms: Level I (Point Source) – refers to a protected well (shallow and
Q deep well), improved dug well, developed spring, or rainwater cistern with an outlet but without a distribution system, generally adaptable for rural areas where
the houses are thinly scattered.
Level II (Communal Faucet System or Standposts) – refers to a system composed of a source, a reservoir, a piped distribution network, and a communal faucet.
Note: For reporting purposes Level II system may also include a communal faucet connected to Level III where group of households get their water supply.
Level III (Waterworks System) – a system with a source, transmission pipes, a reservoir, and a piped distribution network for household taps. It is generally suited
for densely ‐ populated areas.
R Write the word "Yes" or "No". A household with safely-managed drinking water must meet the following three (3) criteria: (1) located inside the household or
within its premises; (2) available at least twelve (12) hours per day AND (3) the water supplied should be free of fecal contamination (E. coli.
S Write "with" or "without" corresponding to the answer in the collecting tool

Note:
> Treat each row individually
> Do not leave any cell blank. Write None for not applicable cell. E.g., family planning or unmet need for children, non reproductive age or other groups.
Municipality: Total Projected Population: Date Accomplished:

Barangay: Total Actual Population: 4/16/2021 12:01:45 AM

HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Access to Safe Water Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Sanitation
Basic Safe Safely-
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
HH No. No. Name of Household Members Relationship to Birthday Age Sex Occupation / Source Average Religion Educational Philhealth Number FP User Unmet PWD (specify) Morbidity (specify) Basic
(Surname, First Name Middle Name) Household Head (mm/dd/yyyy) (Male / of Income (individual) Monthly Income Attainment (Yes / Needs Basic Safe Safely- Sanitation
Female) (individual) (specify) No) (Yes / No) Source: Managed: Facility (with /
without)
(I, II, III) (Yes / No)

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121

121
 ZOD VERIFICATION FORM
Date: Municipality/City Province:
Barangay: Number of Households: Triggering Date (if applicable):
Population:

OBSERVATION OF THE BARANGAY

Household Name/Number: HH # 1 HH # 2 HH # 3 HH # 4 HH # 5 HH # 6 HH # 7 HH # 8 HH # 9 HH # 10 HH # 11 HH # 12 HH # 13 HH # 14 HH # 15
1. Is the toilet being used: (Y/N). If shared, public or communal, please verify the
toilet
2. Is the toilet functional and well maintained? (Y/N)
• well maintained means inside and immediate premises of the toilet is kept
clean
• functional means that toilet is available for use when needed
3. Is there soap and water at or near the toilet? (Y/N)
4. Are children and elderly's feces including anal cleaning materials properly
disposed? (Y/N)
• means that feces from the used diapers are disposed in the toilet facility
andfeces
5. Are there not in
in garbage wastedefecation
former open or together with(Y/N)
sites? domestic waste
6. Aside from former open defecation sites, there are no feces deposited in the open
anywhere in the community? (Y/N)

VERIFICATION AND CERTIFICATION SUMMARY

ZOD CERTIFICATION QUESTIONS YES NO
1. Are there "NO VISIBLE SIGN OF OPEN DEFECATION" in the Barangay? (Check OD sites)
2. Are you convinced that all households are using toilets?
3. Do all households verified have YES response for questions 1-6?
• If answered to the 3 questions are all YES Barangay can be declared as ZOD status
• ZOD Certification status granted (please check)

VERIFIED BY (Check appropriate Verification Team):

( ) Municipal Verification Team

NAME SIGNATURE DATE

1.
2.
3.
4.