APPENDICES

I. FAMILY SURVEY FORM

Respondent: _________________________________________________ Age: _______________

Stage: _______________________________________________________Sex: _______________
Relation to Head: __________________________________________ (If not, the Head of the Family)

I. Family Data
A. Head of the family: _____________________________________ Age:____________________
B. Name of Spouse:_______________________________________ Age:____________________
C. Address:______________________________________________Tel No.__________________
D. Educational Attainment:__________________________________________________________
i. Husband:_____________________________________________________________
ii. Wife:________________________________________________________________
E. Length of Residency:____________________________________________________________
F. Ethnic Origin:__________________________________________________________________
G. Family
Nuclear: ____Extend: _____Cohabitation: _____ Single Parent: ____ Gay/Lesbian: ________
H. Religion
Roman Catholic: ___Muslim:____Iglesia Ni Kristo: ___Born Again: ___Protestant:___Others:__
I. No. of Children_________________________________________________________________
J. Members of the Household

Name Relation to Age Sex Status Education Occupation

the Head

II. Socio-Economic Data

A. Source of Income
Occupation
Husband
Employed: ________ Unemployed: __________ Self-employed:___________
Wife
Employed: ________ Unemployed__________ Self-employed:___________
Joint Monthly Income
Below ₱2,000:__________ ₱ 3,000 - ₱5,000:___________
₱5,001 - ₱8000:_________ More than ₱8,000:__________
B. Basic Expenditures:
1. Food daily
Below ₱ 100:_____________ ₱150-250:__________________
More than ₱ 100:___________ More than ₱250:_____________
2. Clothing: number of times of buying in a year
Once: ___________________ Twice: ________________________
Thrice: __________________ More than four times: ____________
3. Housing
Water: _______________ Electricity: ___________
Telephone: ____________ Internet: _____________
4. Schooling
Public: _____________ Private: ____________Others:_____________
C. Food Preference:
Fish: ____________ Fruit/Vegetables: __________ Junk foods: _________
Meat: ___________ Bread: __________________ Pasta: _____________
D. Containers Used:
Plastic: _____________ Jars: _______________Wood:____________________
Bottles: _____________ Metal: ______________Others:____________________
E. Toilet Facilities
Sanitary:
Flush: ______________Pit Latrine: ___________Septic Tank: ___________________
Antipolo Toilet: _______Aqua Privy: ____________Overhung Latrine: _____________
Ventilated-improved privy: __________________Compost Privy: _________________
Pour-flush latrine: ________Tank-flush toilet: _________Box and Privy: _____________
F. Waste Disposal:
Collection: ____________________ Burning: ______________________________
Compost Pit: ___________________ Open Dumping: ________________________
G. Food Storage:
Covered: _____________________ Uncovered: ___________________________
Refrigerated: __________________
H. Presence of Animals:
Dogs: ________________________ Cats: ________________________________
Pigs: _________________________ Chicken: ______________________________
Birds: ________________________ Fish:_______________Others:____________
I. Backyard Gardening:
Vegetables:___________________ Herbal:_______________________________
Fruit-bearing:__________________ Others:_______________________________
J. Community Observation:
a. Sanitary Condition:______________________________________________________

b. House overcrowding/congestion: Yes ( ) No ( )

c. Presence of breeding sites of vectors: Yes ( ) No ( )
If yes, specify: _________________________________________________________
d. Health facility: Hospital:__Health Center:___Private Clinic:___Albularyo:__Others:_____
 e. Recreational facility: _____________________________________________________
f. Distance of house to the nearest health care facility: ____________________________

K. Common Fare
Rice and egg:_______________ Rice and vegetables:_____________________
Rice and meat:______________ Rice and fish:__________________________

III. Housing and Environmental Condition

A. Home
1. Type of Housing
Concrete:_________________ Wood:__________________________________________
Mixed (Concrete & Wood): ____________Makeshift:_____________Others:____________
2. Ownership
Owned:___________________Rented:_________________________________________
Rent-free:_________________Others: _________________________________________
3. Numbers of rooms for sleeping: ________________________________________________
4. Ventilation:
Poor:____________________Fair:_____________Good:__________________________
5. Lighting facilities:
Electricity:_________________Kerosene:_______________________________________
Solar Panel: ______________________________________________________________
6. General surroundings:
Clean:____________________Dirty:___________________________________________
B. Source of Water Supply:
Deep well:________________Faucet:_______________Waterwork system:___________
C. Storage of Drinking Water:
Refrigerated:_________________Covered:_____________________________________
Uncovered: __________________Others:______________________________________
D. Kitchen:
Electric stove:_________________Gas stove:___________________________________
Firewood/charcoal:_____________Others:______________________________________
E. Drainage:
Open:________________________Blind:_______________________________________
None:____________________________________________________________________
Sanitary observations:
Clean:_______________________Dirty:_____________________

IV. Immunization Status of Children

BCG:______________ OPV:___________ DPT:____________ Pentavalent:____________
Hepa B:____________ AMV:___________ Rotavirus:________

V. Methods of Family Planning

IUD: _____________ Ligation: __________ Pills: _____________
Rhythm: __________ Withdrawal: ________ Condom: __________

VI. Health Information

Health Personnel______ Social Media_______ Radio____________
Television____________ Newspaper/Fliers/Posters_____ Phone____________
Others specify: _____________________________________________________________________

VII. Type of Birth Attendant

Doctor: __________ Midwife: _________ Nurse: __________ Trained Hilot: ______

VII. Mortality: ________________________________________________________________________

I. Morbidity:
_______________________________________________________________________