Scribd Logo
Upload

Welcome to Scribd!

  • NCM 104 Rle Survey Form

    Uploaded by

    Princess Alegre
    11 views1 page
    This document appears to be a survey template containing questions about a respondent's family members, religion, education, occupation, housing, health, sanitation, nutrition, and food production. The survey collects information such as the respondent's family size, ownership and type of housing, leading health issues, prenatal care, immunizations, and means of cooking and water supply. It also documents environmental sanitation conditions like the type of toilet facilities, garbage disposal, and fence status.

    Original Description:

    Original Title

    Ncm 104 Rle Survey Form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document appears to be a survey template containing questions about a respondent's family members, religion, education, occupation, housing, health, sanitation, nutrition, and food production. The survey collects information such as the respondent's family size, ownership and type of housing, leading health issues, prenatal care, immunizations, and means of cooking and water supply. It also documents environmental sanitation conditions like the type of toilet facilities, garbage disposal, and fence status.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    11 views1 page

    NCM 104 Rle Survey Form

    Uploaded by

    Princess Alegre
    This document appears to be a survey template containing questions about a respondent's family members, religion, education, occupation, housing, health, sanitation, nutrition, and food production. The survey collects information such as the respondent's family size, ownership and type of housing, leading health issues, prenatal care, immunizations, and means of cooking and water supply. It also documents environmental sanitation conditions like the type of toilet facilities, garbage disposal, and fence status.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Interview Date: Purok:

    Accomplished by: Barangay:


    Respondent: Municipality:
    Family Members Religion Educational Birthday Age Occupation Income Types of Housing
    Attainment
    Husband:  Concrete
    Wife:
     Wood
    Children:
     Concrete/wood
     Makeshift
    1
    2 Types ownership
    3  Owned
    4  Rented
    5  Rented- free
    6
    7 Residency- Length of
    8 Stay
     1-5 months
    Health Status:  6 months- 3
    years
    Morbidity Leading Status  5 years up
    (Actual Survey)
    Family Planning Family Size
     Practicing  Small (1-4)
     Medium (5-6)
    Name  Not Practicing
     Large ( 7 up)
     Fever
     Cough and cold Family Planning
     HPN Place of Delivery
    Method
     Others (0-12)
     Pills
    Specify_________  Private Hospital
     Condoms
     District Hospital
    Morbidity Leading Causes  Rhythms
     Lying-in Clinics
    (Past 1-year)  Others
     House
    Specify_________
    Name Infant Feeding Practice
     Fever Pregnant Women (0-12)
     Cough and cold  With pre-natal  Breast Feeding
     HPN  Without pre-natal  Mixed Feeding
     Bottle Feeding
     Others LMP
    Specify_________ EDC ________ Kind of Milk

    Mortality Leading Causes Types of Birth Health Facility


    (Past 1-year) Attendance (0-5)  Hospital
     Doctor  Health center
    Specify Name
     RHM  Private Center
     Trainee Hilot  Albularyo
     Others
    Specify: __________
    Immunization Services
    (0-12months) Nutrition Status
    ENVIRONMENTAL SANITATION
     BCG (0-12)
    Toilet Garbage Disposal Garbage Collection  DPT  Normal
     With toilet  Compost pit  C cover  OV  1st Degree
     Pit Privy  Burning  S cover  HEPA- B  2nd Degree
     H2O sealed  Collected  none  Measles  3rd Degree
     Flush  Open Dumping
    Means of Cooking  Over WT
     Without toilet
    Food Storage  Electric stove
    Water Supply FOOD PRDUCTION
     C refrigerator  Wood /charcoal
     Artisian well  S refrigerator  Kerosene
     Water pump  C cover  LPG Herbal Plant Pig
     Distribution  S cover
     Others
    Storage of drinking water Fence
    Strage of drinking water
     C cover Chicken
     Present and adequate Vegetables
     C cover
    S cover
     Need repair
     S cover
     none

    You might also like