Republic of the Philippines

Province of Davao de Oro

Municipality of Laak

Interviewed by: ___________________________________________________________ Reviewed by: ___________________________________________________________

Signature over printed name of BHW Signature over printed name of RHM/NDP

Encoded by: ___________________________________________________________ Date Encoded: ___________________________________________________________

Signature over printed name of Encoder/Designation (mm-dd-yyyy)

HARMONIZED FAMILY / HOUSEHOLD PROFILE

HOUSEHOLD INFORMATION Social Economic Status (Please Tick) NAME OF RESPONDENT DATE OF VISIT (mm-dd-yyyy)

Sitio/ Purok: NHTS 4Ps IP Household Last Name: First Quarter:

Barangay: NHTS Non-4Ps Non-IP First Name: Second Quarter:
Household Number: Non-NHTS Middle Name: Third Quarter:
Renter (Y/N): If Yes, No. of Months: if IP Household, indicate TRIBE: Relationship to HH Head: Fourth Quarter:

Type of Water Source: _________________
Type of Toilet Facility: _________________
Type of Waste Management: ___________
(Please refer to the guide on the right side of this row.)
With blind drainage? Yes
Type of Water Source Type of Sanitary Toilet Facility Type of Unsanitary Toilet No Toilet Type of Waste Management
Level I – Point Source A – Pour/ flush type connected to septic tank E – Over hung latrine G – Without Toilet A – Waste Segregation
Level II – Communal Faucet B – Pour/ Flush Toilet connected to septic tank F – Open Pit latrine B – Backyard Composting
C – Recycling/ Reuse
Level III – Individual Connection AND to sewerage system
D – Collected by City/ Municipal Collection and Disposal System
Others – For doubtful sources, open dug well, C – Ventilated Pit (VIP) Latrine
No etc. D – Water-sealed toilet
E – Others (Burning/ Burying, specify)
(within household compound; not satisfactory method)

Name of Household Members Relation- Sex Date of Civil PhilHealth ID Member Medical Personal/ Social History WRA Classification by Age/ Health Risk Group Education & Remarks
ship of F/M Birth Status Number -ship History Occupation

1
 member (mm-dd- Type HPN - hypertension Smoker Alcohol Sexually Last FP N – Newborn P – Pregnant Educational Attainment; *Note if
N – none transfer
to HH yyyy)
M-married
DM - diabetes Y/N Bev. Active Mens. Use AB – Adult > 25 y.o AP – Adolescent pregnant of
EL – elementary level
Head S-single TB - tuberculosis Drinker Y/N Period Y/N SC – Senior Citizen PP – Postpartum residence
M-member EG – elem. graduate
(Please provide the names of the members of the W-widow/ S – surgery Y/N WRA – 15-49 y.o., not I – Infant (29 days – 11 pregnant
D-dependent mm/ HSL – high school
household starting from the household head widower
dd/yyyy and non-PP mos. old) level HSG – high
1-Head *Nutrition
SPseparate S – School-aged Children U – Under five (0-59 mos) school graduate V –
followed by spouse, son/ daughter <eldest to 2-Spouse d vocational
status of
(5-9 y.o) PWD – person with 0-59 mos.
youngest>, and other members.) 3-Son L-live in A – Adolescent (10-19 y.o) disability CL – college level HH
4-Daughter CG – college graduate member:
5-Others, PG – postgraduate SAM –
specify severe

relation Q1 Q2 Q3 Q4 acute
malnutriti
Class Class Class Class
Last Name First Name Middle Name Age Age Age Age
on
MAM –
Mode
rate
acute
Educ Occupation malnu
trition
ST –
stunte
d
Up – for
updating

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