PROVINCE OF CEBU

CITY OF CARCAR
BARANGAY PERRELOS

HOUSEHOLD PROFILE QUESTIONARE

A. Identification of Location

Province:
City:
Barangay:
Purok:

Household Identification Number:

Household Address:

B. Demography
FULL NAME RELATED TO THE M/F MM/D AG CIVIL YRS IN WHERE WAS THE LAST
(LAST,FIRST, MIDDLE) FAMILY D E STATU BRGY. BARANGAY BEFORE
YYYY S BRGY. PERRELOS

C.EDUCATIONAL AND LITERACY/COMMUNITY AND POLITICAL PARTICIPATION/NUTRITIONAL STATUS

NAME(LAST NAME) GRADE/YEAR PUBLIC/ NAME YES/NO DID NUTRITIONAL
ATTENDING PRIVATE OF VOTER HE/SHE STATUS OF
ORG.IF VOTE CHILDREN 0-
MEMBE LAST 5.
R ELECTIO
N
D. ECONOMIC ACTIVITY
FULL NAME WHAT IS THE NAME OF NATURE CLASSIFCATIO MEMBER OFW SOLO PARENT/PWD
PRIMARY JOB THE OF THE N OF THE JOB NOT IN SENIOR CITIZENS
COMPANY JOB THE PROFESSIONAL(WRITE
HOUSE THE POSITION)

E. WATER AND SANITATION/HOUSING/SOURCE OF INCOME

WHAT IS YOUR HOUSEHOLD’S MAIN SOURCE OF DRINKING WATER?______________________

WHAT KIND OF TOILET FACILITY DOES THE HOUSEHOLD USE? ___________________________

WHAT IS THE TENURE STATUS OF THE HOUSING UNIT AND LOT OCCUPIED? __________________________

IS THERE ELECTRICITY IN THE HOUSE? ___________________________

WHAT THE SOURCE OF ELECTRICITY? _______________________________

HOW MUCH DOES YOUR ELECTRICITY CONSUMPTION PER MONTH?__________________

WHAT ARE YOUR ITEMS IN YOUR HOUSE?_________________

WHAT TYPE IS YOUR HOUSE?_____________________

WHAT IS THE SOURCE OF INCOME?

F. AGRICULTURAL

WHAT IS THE TENURE STATUS OF THE HOUSE OF THE AGRICULTURAL LAND? ________________

WHAT IS THE AREA OF THE LAND? __________________

WHAT TYPE OF CROP OR FRUIT -BEARING TREES DID YOU HARVEST? ___________________________

G. LIVESTOCK RAISING/WASTE DISPOSAL

WHAT WERE THE LIVESTOCK OR POULTRY THAT YOUR HOUSEHOLD RAISED TO EARN MONEY? HOW MANY ?

WHAT IS THE SYSTEM OF GARBAGE DISPOSAL BY THE HOUSEHOLD? ______________________

WHO COLLECT THE GARBAGE? __________________

HOW OFTEN IS THE GARBAGE COLLECTED? ____________________

I. NATURAL CALAMITIES/ FOOD ADEQUACY

WAS YOUR HOUSEHOLD AFFECTED BY NATURAL DISASTERS? ______

WHAT WAS THE NATURAL DISASTER THAT AFFECTED YOUR HOUSEHOLD? _________________

DID HAPPEN EVEN ONCE THAT YOUR HOUSEHOLD EXPERIENCED HUNGER AND NOT HAVE ANYTHING TO EAT? ___

HOW MANY DAYS ?

J. ACCESS TO PROGRAMS

FULL NAME NAME OF YEAR WHO IMPLEMENTED THE HOW DID THIS PROGRAM
PROGRA PROGRAM AFFECT YOUR FAMILY
M AVAIL

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SIGNATURE OVERPRINTED NAME/DATE

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SIGNATURE OF PUROK REPRESENTATIVE