Saint Paul University Philippines • Age of House:

Tuguegarao City, Cagayan Valley 3500 0-5 - 0

6-10 - 0
DATA BASELINE SURVEY FORM 11-15 - 3

* Materials used:
A. Family Size: • Concrete 3 • Wood 0 • Bamboo 0 • Mixed 3
Number of Adults: _4_ Male _4 Female
Number of Children: _9_ Male _3_ Female * Number of floors:
• One 3 • Two • Three 0 • Four 0
B. Marital Status:
• Single: _6_ Male _2_ Female * Lighting Facility:
• Married: _5_ • Electric Bulb 3 • Candles 0 • Gas Lamps 0
• Widow: _1__ • Widower: ___
• Separated: _2__ * General State of Repair:
• Roof 0 • Floor 0 • Walls 0
C. Educational Attainment: • Ladder 0 • Window • Door 0
• Elementary Undergraduate: _1__ Male _1_ Female • Foundation 0 • Roof Braces 0 • Rooms 0
• Elementary Graduate: ___ Male _ Female • Sink 0 • Kitchen 3 • Toilet 0
• Highschool Undergraduate: __1_ Male ___ Female
• Highschool Graduate: __ Male ___ Female K. Hangouts:
• College Undergraduate: __1_ Male _2__ Female • Store 1 • Waiting Shade 1 • Court 0 1 • Yards 3
• College Graduate: _4_ Male _4__ Female • House 3
• TechVoc Course Graduate: _0__ Male _0__ Female
L. Animals:
D. Occupation: • Dogs: 3 Cats: 0 • Pig: 8 • Chicken: 11 •
• Farmer: _3___ • Carpenter: _0_ • Housewife: _1_ Duck: 4 • Bird: 0 • Goat: 0 • Carabao: 1
• Driver: _0___ • OFW: _3___ • Cow: 1
• Others, specify: .
_____________ M. Water (drinking):
* Source: • Faucet 0 • Deep Well 0 • Pump Well 3
* Ownership: • owned 2 • shared 1
E. Religion: * Storage: • Refrigerated 0 • Not refrigerated 3
• Roman Catholic: _3 • Covered 3 • Not covered 0
• Baptist: 0
• Born Again: _0__ M. Water (general usage):
* Source: • Faucet 3 • Deep Well 0 • Pump Well 2
F. Types of Family: • Drum 2 • Jags 01 • Bottles 0 • Pail 3 • Jar 0
• Dyad 2 • Nuclear 1 • Extended 0
• Blended 0 • Single Parent 0 * Storage: : • Refrigerated 0 • Not refrigerated 3
• Covered 3 • Not covered 0
G. Authority: • Drum 2 • Jags 3 • Bottles 0 • Pail 3 • Jar 0
a. Decision Making:
• Patriarchal 0 • Matriarchal 0 • Egalitarian 3 * Usage: • Bathing 3 • Cooking 3 • Laundry 3
b. Child Discipline:
• Patriarchal 0 • Matriarchal 0 • Egalitarian 3 N. Food:
c. Healthcare Decisions: * Cooking facility: • Firewood 1 • Gas stove 3
• Patriarchal 0 • Matriarchal 0 • Egalitarian 3 • Charcoal 0 • Electric Stove 1
d. Financial Management: * Storage: • Refrigerated 0 • Not refrigerated 3
• Patriarchal 0 • Matriarchal 0 • Egalitarian 3 • Covered 3 • Not covered 0

H. Signs and Symptoms: * Usual Number of Meals per day: 3x a day: 3

• Head ache: _0__ • Colds: _0__ * Usual Composition:
• Cough: _0__ • Fever: _0__ • Vegetable 3 • Fish 3 • Chicken 3 • Meat 3
• Hypertension: _1_ • TB:_0_ • DM: _0__ • Fruits 3 • Rice 3 •pork 3 •beef 3
• Diagnosed by a practitioner? • Yes: _1__ • No: ___
O. Exercise:
I. Number of Pregnant Women: • Yes: 3 • No: 0
● AGE <15 * Types:
• Age 15 – 19: _0__ • Age 20 – 24: _0___ • Jogging: 2 • Walking: 2 • Work: 2
• Age 25 – 29: _0__ • Age 30 – above: _0___ • Biking: 2 • Stretching: 2

J. Housing:
P. Vices: * Social Facilities Available:
• Smoking: 0 • Courts 3 • Waiting shades 0
• Drinking Alcohol: Ocational 3
* Heathcare Facilities Available:
Q. Leisure and Recreation: • Botika 0 • Health Center 3
• Chatting: 3 • Listening to radio: 1 • Sports: 1
• Sleeping: 3 • Walking: 1 • Watching TV: 3 * Healthcare Providers Present:
• Playing cards: 0 • Nurse 3 • Doctors 0 • Midwives 3
• Trained Hilot • Albularyo 3
R. Toilet:
* Ownership: • owned 3 • shared 0 * Health Services Offered:
* Type: • Flush 0 • Pail system 0 • Immunization • Health Education 0 • Check –
• Open pit 1 • Close pit 0 ups 2
• Water sealed 3
* Distance: • 2 – 3M 3 • 4 – 5M 1 • 6 – 7M 0 * Level of Satisfaction:
• 8 – 9M • 9 – 10M 0 • Very Satisfied 2 • Satisfied 1
• 11 – above 0 • Not Satisfied 0

S. Garbage: * Frequency of Visiting Healthcare Facilities:

* Container used: • Trashcan 0 • Plastic • Once 0 • Twice 0 • Thrice 0
• Sack 3 • Box 0 • Pail 0 • Hole 0 • As needed 3
* Method: • Burning • Composting 5
• Open dumping 0 * Name of Healthcare Provider/s:
* Waste Segregation: • Yes 3 • No 0 1. Nena martines
2. Josefina Dayos
T. Drainage System: 3. Julianne Esquivel
* Type of Drainage: • Open 3 • Close 0
* Household drainage: • Open 0 • Close 0 * Reasons for Visiting Health Centers:
• None 3 • Health Education 0 • Check – up 2 • Medicine 3
• Feeding Program 0
U. Transportation:
• Jeepney 0 • Truck 0 • Motorcycle 3 * Name of Organizations:
• Tractor 1 • Tricycle 1 • Van 1 1. RHU roxas

V. Income:
* Who earns? • Mother • Father 2 Zone #1:
• Both Parents 2 • Children 1 • All 1  Dionicia Plado
Zone #2:
* Source: • Farming 1 •__2_ Self- employment  Roderick P. Taguiam
• Pensions 0
 Jhovielyn Viernes
* Monthly income:
• 0 – 500 0 • 501 – 1000 0 • 1001 – 2000 0
• 2001 – 3000 0 • 3001 – 4000 0
• 4001 – 5000 0 • 5001 – above 3

* Expenditure: • Clothing 2 • Education 3 • Food 3

• Farm 3 • Housing 1 • Medicine 1

* Products: • Rice 3 • Corn 0 • Vegetables 3

• Poultry 3
* Land ownership: • Tenant 0 • Owned 3

W. Other Information:
* Protective Services Available:
• Police 3 • Army 0 • Tanod 3
•security guard 0

* Security Facilities Available:

• Streetlights 3 • Road humps 0 • CCTV 0
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
COLLEGE OF NURSING
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
First Semester, AY 2021-2022
COMMUNITY HEALTH NURSING
Barangay Luna , Roxas, Isabela
OCT. 16, 2021
 
PHOTO DOCUMENTATIONS 

 
WHO: Student Nurse
WHAT: Data Baseline Survey
WHERE: Barangay Luna , Roxas, Isabela
WHEN: OCT. 16, 2021