HOUSEHOLD SURVEY FORM

INSTRUCTION: Please provide the answers to the questions below. No questions must be left unanswered. For question/s which
is/are not applicable, kindly write N/A.

I. FAMILY MEMBERS AND CHARACTERISTICS

A. Basic Information About HEAD OF THE FAMILY

Name: Mr. Orji Patrick Birthdate: 19/05/1954 Age: _67_ Sex: _male_
Highest Educational Attainment: college Occupation: Business man_ Monthly Income: 25000

Civil Status:

 Married □ Legally □ Common Law

 Widowed
 Separated
 Single

Employment Status:

 Permanent □ Private □ Public

 Temporary □ Casual□ Contractual
 Self-employed
 Unemployed

B. Other Family Members:

No. of children in the household:
Total: __3_____ Male: ___2__ Female: __1___
No. of other dependents in the household:
Total: __2_____ Male: _1____ Female: __1___

RELATION HIGHEST
TO HEAD AG CIVIL EDUCATIONA OCCUPATIO MONTHL
NAME SEX
OF THE E STATUS L N Y INCOME
FAMILY ATTAINMENT
Orji Patrick husband 67 male married college Business man 25000
Orji Charity wife 56 female married college Teacher 15000
Orji Celeb son 32 male single college Civil servant 10000
Orji Onyeka son 28 male single college NA NA
Orji Chioma daughter 24 female single college NA NA

**NOTE:
 For children ages 3-5, indicate under educational attainment column whether attending daycare or not.
 For children ages 6-16, state whether currently studying or not under occupation.

II. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

A. Religion: (please specify) _catholic_
B. Primary dialect/ language spoken at home: _English, igbo
C. Income:
C.1 Estimated average family income per month (total family income: from A and B, please check)
Above 50,000______ P30,001-35,000 _√ ____ P10,000-15,000____
P45,001–50,000 ____ P25,001-30,000 _____ P5,001-10,000 ____
P40,001-45,000 ____ P20,001-25,000_____ P1,001-5,000 _____
P35,001-40,000_____ P15,001-20,000_____ P1,000 & below____

C.2 Primary source of Livelihood:

Farming _____ Owned: _√ ___ Tenanted: ____
Laborer: _____ Carpentry: _____

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 Fishing: ______ Peddling: _____
Government Employee: ______
Small Industries: (sari sari store, carenderia, etc. )_____
Others (specify): ____

C.3 Food Production Engaged in (may check more than one): _____ yes, ____no
(if yes, please answer below)

RESOURCES FAMILY SELLING BOTH

CONSUMPTION
Vegetable gardening NA NA NA
Piggery NA NA NA
Poultry NA NA NA
Fruit trees NA NA NA
Others: (pleases specify) NA NA NA
__________________

__________________

D. Real Property
D.1 Type of property owned:
___ Farmland (rice, coconut, others)
 ___ Residential Lot
___ Residential lot with house
___ Commercial Lot with building
___ Others (Specify)
D.2 Housing:
a. ownership: √ ___ owned ____ rented ___ shared
b. type of construction:
_√ __ light
___ medium (wooden floors/walls with nipa roof)
___ heavy (dominantly concrete/ hardwood with galvanized sheets)
D.3 Facilities:
a. Type of appliances owned:
_√ __ radio √ ___ CD _√ __ Electric Fan
_√ __ cassette _√ __ DVD _√ __ refrigerator
_√ __ TV _√ __ Gas burner _√ __ Computer Set
_√ __ Laptop ___ Others: (specify) _____________________

b. Vehicles owned: (for people and/or goods)

_√ __ car ___ tricycle ___ others (specify)
___ private jeep ___ motorcycle _____________________
___ truck ___ kuliglig _____________________

c. Utilities
_√ __ Electrical connection

_√ __ Telephone / cellphone

D.4 All family members with basic clothing of at least 3 sets of external and internal clothing:
___ yes ___ no

D.5 Family Consumption:

Family Food Consumption Adequate (please check) Inadequate (please check)

Eat 4 times or more
Eat 3 times a day √
Eat twice a day
Eat once a day

E. Decision making pattern (please check the appropriate column, you may check more than one)

DECISION AREA FATHE MOTHE CHILDRE SINGLE

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 R R N
Family Expenses √ √
Health √ √
Education √ √
Participation in Community activities NA NA

III. HEALTH STATUS AND PRACTICES

A. Food, nutrition and Immunization Status (children 0-72 months old)

a.1 Infants exclusively breastfed for four months:

Name of Child Exclusively breastfed for 6 months If NO, state reason

YES NO
Orji Onyeka Yes
Orji Chioma Yes
Orji Celeb yes

a.2 Supplementary feeding: (children 0-72 months old)

Name of child Supplementary feeding If yes, what were the types of food given? Age started
Yes No
Orji Celeb Yes
Orji Onyeka Yes
Orji Chioma Yes

a.3.1 Nutritional Status of children 0-72 months

Name Birthdate Date of Weight Status Height Status

Weighing
Orji Celeb 10/5/1989 NA NA NA NA NA
Orji Onyeka 20/9/1995 NA NA NA NA NA
Orji Chioma 11/6/1997 NA NA NA NA NA

a.3.2 Immunization Status (Children 0-12 months old)

Name Age in Types of Immunization

months BCG OPV1 OPV2 OPV3 PCV1 PCV2 PCV3 IPV MM Penta MM Status
R R
Celeb NA √ √ √ √ √ √ √ √ √ √ √ NA

NA √ √ √ √ √ √ √ √ √ √ √ NA
Onyeka
Chioma NA √ √ √ √ √ √ √ √ √ √ √ NA

B. Prenatal, Natal and Postnatal Care (to be answered if there were pregnant/lactating mothers and deliveries in
the past year)
1. Pregnant and lactating mothers provided with Iron and Iodine supplementation:
__√ __ yes ___ no
2. Pregnant mothers given at least 2 doses of Tetanus toxoid:
_√ __ yes ___ no
3. Pregnant mother given prenatal care: _√ __ yes ___ no
3.1 First visit made in the first trimester _√ __ yes ___ no
3.2 Had at least 1 visit per trimester _√ __ yes ___ no
3.3 Total number of pre-natal visit: _3___

4. Postnatal visit within 4-6 weeks postpartum: __√ __ yes ___ no

5. Delivery handled by trained health personnel: √ ___ yes ___ no

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 If yes, specify: ___ trained hilot
___ RHM
_√ __ Nurse
___ Physician
If no, who handled the delivery? (specify) _______________________

C. Family Planning (To be answered by MCRA’s in the household):

1. Couples with access to family planning services: _√ __ yes ___ no
2. Couples practicing family planning: _√ __ yes ____ no
If yes, specify method: _________NA_______________
If no, state reason: ____________________________

D. Morbidity (Past 1 year, please counter-check with secondary data)

1. Any of the children below 6 years old had more than 1 diarrheal episodes: ____ yes ___ no
2. Other illnesses experienced by family members:

Type of Illness Age Sex Health worker attended Treatment used

MALARIA 2 male physician Anti-malaria drugs

E. Mortality (Past 1 year, please counter-check with secondary data)

1. With deaths in the family due to preventable diseases (past 1 year): ____ yes ____ no
2. Causes:

Type of Illness Age Sex Health worker attended Treatment used

NA NA NA NA NA

F. Health Seeking behavior and Utilization of Health Services:

1. Family member with Phil health:

Name Status Remarks

NA NA NA

2. Family members avail of health services: ___ yes _√ __ no

3. With solo parent availing health services: ___ yes __√ _ no
4. Delays in accessing health care
a. Reasons in delaying decisions to seek health care:
__√ _ Failure to recognize danger signs
___ lack of money to pay expenses
___ No available person to take care of the children and home
___ Lack of companion in going to the health facility
___ others; specify _________________________
b. Reasons for reaching appropriate care in a health facility
___ Distance of home to a health facility
___ Lack of transportation
___ others: specify ______NA_______________________
c. Delays in Receiving appropriate care in a facility
___ Shortages of supplied and basic supplement in a health facility
___ lack of skilled health personnel in the hospital
___ Poor skills of health care providers
___ Others: specify ________________________________
5. Health services most frequently availed of: (please rank)
___ RHU _√ __ Private Clinic
___ BHS _√ __ Hospital __√ _ private ___ public
6. Health worker preferences during illness (rank using numbers according to who is seen first)
___ Medicine man _1__ Nurse others: specify ________________
___ Midwife __2_ Doctor
7. Health interventions done during illness (Rank using numbers according to who is seen first):

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 _1__ Self-Medication: Specify ____________________
___ Consult medicine man (Albularyo)
___ Consult RHM
___ Consult Nurse
_2__ Bring Patient immediately to the hospital
___ Others: specify ________________________

IV. ENVIRONMENTAL CONDITION

a. Safe water
1. Access to safe drinking water within 250 meters or 10 minutes’ walk from their home:
_√ __ yes ___ no
2. Water source (please check):
Level 1: _√ ___ Protected well
____ Developed spring
Level 2: __√ __ Piped distribution network and communal faucet
Level 3: _√ ___ Waterworks system for individual households
Others: ____ Shallow dug well
____ Unprotected spring
____ Others: (Specify) ______________________________
3. Method of water storage: ____ open container _√ ___ covered container
4. Method of water treatment: ____ chlorination _√ ___ boiling ____ no treatment

b. Method of Excreta Disposal:

Types: _√ ___ WST owned:

√ ___ functional ____ non-functional

____ WST shared:
___ functional ____ non-functional
____ without, specify: _________________________________

c. Method of Domestic Water waste Disposal: _√ __ Blind drainage ___ Open Drainage

d. Method of Garbage collection and disposal (common HH practices):

Collection: _√ ___ open receptacle ___ none
____ covered receptacle

Disposal: ____ composting ____ burying

____ burning _√ ___ open dumping
____ riverside dumping ____ others

e. Method of animal management:

Kind of animals: specify: _____________ ___domestic _____ agricultural
_____ tied ____ fenced ____ astray
_____ both _√ ___ no animals
f. Food Storage:
_√ ___ cabinet _√ __ covered plates ___ others: specify
__√ __ covered basket _√ __ refrigerator ____________________

V. PEOPLES PARTICIPATION IN COMMUNITY DEVELOPMENT:

1. Family members involved in at least one legitimate people’s organization / community development:
____ yes__√ __ no
2. Number of family members involved: __ NA_____
3. Name in organization involved in (specify):
_______________NA___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

4. Awareness in existing organizations:

List name of organizations known to be respondent even if not a member:
____________NA______________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________________________

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 5. Participation in other community activities / projects:
List projects / activities participated in:
_______________NA___________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

VI. COMMUNITY RESOURCES, NEEDS AND PROBLEMS:

A. MANPOWER:

Recognized leaders / Community members that can be tapped in the implementation of community projects:

NAME POSITION SPECIALIZATION

NA NA NA

B. MATERIAL

Identify available material resources in the community that can be used for community projects, specify:
_____________NA_____________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________

C. Needs and Problems:

Based on your perception, identify at least 3 most important problems and possible solution that can affect
the health and development of your community”

PROBLEMS RECOMMENDATIONS
Keep the environment clean
Malaria
Wear face mask and face shield
Spread of COVID-19
Keep animals and pets away from the streets.
Rabbies

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