COMMUNITY SURVEY

Region: ____________________ Province: _____________________

Barangay: ___________________ Street: _______________ Zone: ______________ Coordinates:
City/Municipality: __________________ Latitude: _________
Longitude: __________
A. Land formation B. Water formation
( ) Plains ( ) River ( ) Ocean
( ) Mountain range ( ) Falls ( ) Spring

Informant: Position in the family: Gender: F() M() Age:

Note: If the Informant is an extended family, please specify the years living with the family and may need verification from other members of the family or significant others.

Alternative informant: Age: Relation to the family: __________ Years: ______

Verified by: _________________ Age: Relative ( ) Neighbor ( ) friend
( ) other: specify __________

A. FAMILY BACKGROUND
1. Name of Family Head/Respondent:
Gender: F() M() Age: Birthday :
2. Education of the head of the Family:
( ) Employed full-time (40+ hours a ( ) Unemployed ( currently looking ( ) Employed part-time (less ( ) Unemployed ( not currently
3. Current employment status: week) for work) than 40 hours a week) looking for work) ( ) Retired ( ) Self- employed

4. total number of family members:

NAME OF FAMILY MEMBERS

NAME: Birth date Relation with head Age Sex Civil Status Highest Educational Attainment
1 None Elem HS College In School
2
3
4
5
6
7

5. type of the family: 7. Ethnic Affiliation:

( ) nuclear ( ) extended ( ) Tagalog ( ) Ilocano ( ) Muslim: please specify : __________________________
( ) joint ( ) Single parent ( ) Cebuano ( ) Ilonggo

6. Religion of the family

( ) Christianity ( ) Islam
> How many are Islam in the Family?____ > How many are Christian in the Family?_____

HOUSING AND HOUSEHOLD CHARACTERISTICS

House/Building number: ________________ Unit number: _______________

>In what type of building does the household reside?
( ) Commercial/ Industrial/
( ) Single house ( ) Mult -unit (three units or more such Agricultural building/house (e.g.
as appartments,condominiums, etc) office, factory , or others)
( ) Institutional living quarters (e.g. ( ) Other housing unit (e.g. boat,
( ) Duplex dormitories, lodging house and cave, barges, carts and others)
others.)

> How many Bedroom does this housing unit have?

> How many nuclear families are there in the household?
>How many members are there in the househild, including OFWs?

ECONOMIC STATUS

>What is your main source of livelihood?

If farming, what is the condition of your farm?
a. Own land, how many acres?
b.leased land, how many acres?

c. What are the farm yields?

Production cost including laborer
PRODUCTS INCOME PER YEAR etc. per year NET INCOME

>If a worker, what is your employment status?

( ) Full time/ Regular/Permanent ( ) Contractual ( ) daily ( ) seasonal

> If a Professional employee, what is your employment status?

( ) Full time/ Regular/Permanent ( ) Government employee ( ) Private ( ) Part time ( ) Contractual job

HEALTH AND NUTRITION

>During the past 12 months, did you or any member of the household avail of medical treatment for any illness?
( ) yes ( ) no ( ) Did not get sick

> During the last illness of any member of the houseold, where did you go to avail medical treatment?
( ) Public Hospital (National) ( ) Public Hospital (District) ( ) Private Hospital/Clinic ( ) Barangay Health Station ( ) others, specify_______
( ) Non-medical/ non-trained/
( ) Public Hospital (Provincial) ( ) Public Hospital (Municipal/City) ( ) Rural Health Units Hilot/Personnel

For 60 years old and For 5 years old and below

above

Is a solo parent taking care of Does have any physical What type of disability does Does have PWD's ID? Does have senior Date of record of
Nutritional status of
Write the first names of each member Is pregnant? a child/children or mental disability? have? (see below) citizen ID? barangay nutritional
children 0-5 years old
scholar
YES/NO YES/NO YES/NO (see below the table) YES/NO YES/NO

Disability
1. Total Blindness 5. Partially deaf 9. one leg 13. retarded 17. others, specify ______
2. Partial blindness 6. oral defect 10. no legs 14. mentally ill
3. low vision 7. one hand 11. mild cerebral palsy 15. mental retardation
4. total deaf 8. no hand 12. severe cerebral palsy 16. Multiple Impairment

Nutritional status
1. above normal 3. below normal (moderate)
2. Normal 4. below normal ( severe)

WATER, ENVIRONMENT AND SANITATION

>What is your household main Water Supply?

( ) Tubed/piped shallow well ( e.g.
( ) Own use faucet, community water system ( ) Own use tubed/piped deep well Poso, etc.) ( ) Protected Spring ( ) lake, river, rain and others
( ) Shared faucet, community water system ( ) Shared use tubed/piped deep well ( ) dug well ( e.g. balon) ( ) unprootected Spring ( ) bottled water (purified, distilled, mineral)

> How far is this water source from your house? In Meters, _____

> What type of toilet facility does the household use?

( ) Water-sealed, sewer septic tank, use exclusively by ( ) Water sealed, other depository
household used exclusively by household ( ) close pit ( ) pail system
( ) Water-sealed, sewer septic tank, shared by other ( ) Water sealed, other depository ( ) None (bodies of water,
households shared by other households ( ) open pit backyard, public spaces)

> Is there any electricity in the dwelling place? ( ) yes ( ) no

> What is the source of Electricity in the dwelling place?
( ) Electric company ( ) solar ( ) others, specify:_______
( ) Generator ( ) battery

> Does any member of the household have access to

internet? ( ) yes ( ) no

WASTE MANAGEMENT

> What is the system of garbage disposal adopted by the household?

Select all that apply:
( ) Garbage collection ( ) composting ( ) Wastes segregation ( ) pit without cover ( ) others, specify.____________
( ) throwing of garbage in
( ) Burning ( ) recycling ( ) pit with cover River, vacant lot,

> Who collects the garbage?

( ) Municipal/ City collector ( ) Barangay Collector ( ) private collector ( )others, specify

> How often is the Garbage collected?

( ) Daily ( ) thrice a week ( ) twice a week ( ) Once a week, ( ) others, specify_______

WELFARE

During the past 12 months, did you or any member of your household receive or avail of any Who implemented this program?
of the following programs?
Type of program YES / NO ( ) National ( ) Congress/ District
1. Sustainable Livelihood Program ( DSWD ( ) Province ( ) City/ Municipality
2. Food for School ( ) Barangay ( ) Private Organizations?
3. Food for Work ( ) Don't know
4.Cash for Work ( ) Others, specify

5. Social Pension for the Indigent Senior Citizens >What is the name of the Program?
>How many household members are covered by or are members of this program?

>Name of household member/s who is/are beneficiary/ies of the program?

RECREATION
> Are sports Facilities available in the community? ( ) Open sports facilities

( ) yes ( ) no ( ) closed facilities

What are the Family's favorites sports?

( ) Basketball ( ) Badminton ( ) others, specify _______
( ) Volleyball ( ) Baseball
SAFETY AND TRANSPORTATION
>What mode of transportation is most commonly ( ) motorcycle ( ) van ( ) tricycle ( ) bus
utilized in the community?

COMMUNICATION SYSTEM
What is the family's native tounge? ( ) English ( ) tagalog ( ) Bisaya ( ) Ilonggo ( ) Muslim: please specify __________

SOURCE OF INFORMATION
>newspaper ( ) always ( ) sometimes ( ) never
> radio ( ) always ( ) sometimes ( ) never
> TV ( ) always ( ) sometimes ( ) never
> Internet ( ) always ( ) sometimes ( ) never
> Mobile Phone ( ) always ( ) sometimes ( ) never
> others, specify ( ) always ( ) sometimes ( ) never

POLITICAL STATUS IN THE COMMUNITY

>Who do you usually approach when you have a social problem?

Name: ________________________ Role in Society:______________

> Do you participate in social Activities? ( ) yes ( ) no

If yes, please fill up table below
Type of Organization WHO? Relation with the household head officer Member Active Non- actiive

For 18 years old and above

Is a registered voter? Did vote in the last election?
( ) Yes ( ) Yes
( ) No ( ) No