FORM 1 VN 05201701

COMMUNITY-BASED MONITORING SYSTEM

Household Profile Questionnaire

III. Coordinates
A. IDENTIFICATION A.1 Latitude:
A.2 Longitude:
I. Location
a.1 Region IV. Name of Household Head: _______________________
a.2 Province: V. Name of Respondent: ____________________
b. City/Municipality: VI. Start Date of Interview: _______________________
c. Zone: VII. Time Started:________________________________
d. Barangay: VIII. End Date of Interview: _______________________
e. Purok/Sitio: IX. Time Ended: _______________________________
f. Street: ____________________________________ X. Name of Enumerator: ________________________
g. House/Building Number: _______________________ XI. Name of Field Editor: ________________________
h. Unit Number: ________________________________ XII. Date of Field-editing: ________________________
II. Household Control Number (HCN):

B. HOUSING AND HOUSEHOLD CHARACTERISTICS

(1) In what type of building does the household reside?

1 Single house 3 Multi-unit residential (three units
2 Duplex or more such as apartment, accessoria,
condominium, etc.)
4 Commercial/ industrial/ agricultural
building/house (e.g. office, factory, or others)
5 Institutional living quarters (e.g. dormitories, lodging houses
and others)
6 Other housing unit (e.g. boat, cave, trailers,
barges, carts, and others)

(2) How many bedrooms does this housing unit have?

(3) How many storeys does this housing unit have?

(4) What type of construction materials are the
roofs made of?
Strong materials (e.g. galvanized iron, aluminum, tile,
1 1
concrete, brick, stone, asbestos)
2 Light materials (e.g. cogon, nipa, anahaw)
3 Salvaged/makeshift materials (e.g. tarpaulin, tent)
4 Mixed but predominantly strong materials
5 Mixed but predominantly light materials
6 Mixed but predominantly salvaged materials
(5) What type of construction materials are the
outer walls made of?
Strong materials (e.g. aluminum, tile, concrete, brick,
stone, wood, plywood, asbestos)
2 Light materials (e.g.bamboo, sawali, cogon, nipa, anahaw)
3 Salvaged/makeshift materials
4 Mixed but predominantly strong materials
5 Mixed but predominantly light materials
6 Mixed but predominantly salvaged materials

(6) What type of construction materials are the floors made of?
1 Marble 5 Parquet, polished wood
2 Ceramic tiles 6 Palm/Bamboo
3 Cement 7 Wood planks
4 Vinyl, linoleum 8 Natural floor (earth, sand, dung)

(7) How many nuclear families are there in the household?

(8) How many members are there in the household, including OFWs?
 HCN: ______________

C. DEMOGRAPHY
(9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20)
FOR 10
What is YEARS FOR 10 YEARS OLD AND FOR 3 YEARS OLD
Who is the head OLD AND ABOVE AND ABOVE
of the household?__'s In which Was ___’s
ABOVE
relation- nuclear birth regis- What is
N Is __ When is What is __'s
ship to the family tered with What is __'s Where is
U male or __'s date ethnicity by Is ___
head of does the civil ___'s religious ___'s Where was __
Who are the female? of birth? blood? an
M the ___ registry marital affiliation? country of residing 3 years
B other members of household belong? office? overseas
(civil) destination ago?
E the household? ? worker?
status? ?
R
SURNAME 1. Yes 1. Yes
(SEE A (SEE 1. Same address now
1. Male MM/ DD/ RELIGIOUS (GO TO (19)) COUNTRY OF
FIRST NAME CODES G CODES ETHNICITY
AFFILIATION DESTINATION
2. Other address,
2. Female YYYY
BELOW) E 2. No BELOW) specify
MIDDLE NAME 2. No

10

(10) Relation to head of the household (15) Marital (Civil) Status

1 Head 5 Grandson/Granddaughter 9 Step-son/Step-daughter 1 Single 4 Divorced/Separated
2 Spouse 6 Father/Mother 10 Others, specify 2 Married 5 Common-law/Live-in
3 Son/Daughter 7 Other relatives, specify 3 Widowed 6 Unknown
4 Son-in-law/Daughter-in-law 8 Housemaid/boy

CBMS Form 1 PAGE 2

 HCN: _________

D. EDUCATION AND LITERACY E. POLITICAL PARTICIPATION

(21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33)
FOR 3 YEARS OLD AND ABOVE FOR 10-64 YEARS OLD ONLY FOR 5 YEARS OLD AND ABOVE FOR 15 YEARS OLD AND
IF YES IN (21) IF NO IN (21) ABOVE

How many skills IF NOT AT LEAST HIGH SCHOOL IF YES IN (32)

FOR 3–24
training have _______ GRADUATE
YEARS OLD If at least
What is the If senior high attended including the
college Is ___
Is ___ highest school Have ____ current one?
What grade or graduate, currently
N currently Where does educational graduate, attended any Is ___ a
year is ___ what is attending Did ___
U attending __ attend attainment what is skills training registered
currently Why is __ not completed by _______'s _____'s any skills Can ___ read and write a vote in the
M school? school? in the past? voter?
attending? attending college training? simple message in any last
B __? track/strand? Select training
school? course? language or dialect? election?
E programs
R

1. Yes 1. Public 1. Yes 1. Yes NUMBER 1. Yes 1. Yes 1. Yes

(SEE CODES (SEE CODES (SEE CODES (SEE CODES
2. Private COURSE 2. No 2. No
2. No (GO TO BELOW) BELOW) BELOW) BELOW) 2. No (GO TO TRAINING 2. No (GO TO
2. No
(24)) (31)) PROGRAM (34))
3. Don't know

10

(22) Grade level (24) Reason for not attending school

00 No Grade JUNIOR HIGH SCHOOL POST SECONDARY 51 ALS Elementary
01 Day Care 17 Grade 7 23 1st Year PS/N-T/TV 1 Schools are very far 10 Cannot cope with school work
52 ALS Secondary
18 Grade 8
02 Kindergarten/ 24 2nd Year PS/N-T/TV 2 No school within the brgy 11 Finished schooling
53 SPED Elementary
19 Grade 9 COLLEGE 3 No regular transportation 12 Problem with school record
54 SPED Secondary
GRADE SCHOOL 20 Grade 10 31 1st Year College 4 High cost of education/ 13 Problem with birth certificate
11 Grade I 32 2nd Year College Financial concern 14 Too young to go to school
12 Grade II SENIOR HIGH SCHOOL MASTERS/PHD 5 Illness/Disability
33 3rd Year College 15 Got pregnant
13 Grade III 21 Grade 11 34 4th Year College or 41 Post Grad w/ units 6 Housekeeping/Taking care of 16 Others, specify
14 Grade IV 22 Grade 12 siblings
15 Grade V 7 Marriage/Cohabitation
8 Employment/looking for work

(25) Highest educational attainment

00 No Grade JUNIOR HIGH SCHOOL POST SECONDARY (26) Track/Course
51 ALS Elementary 6 Agri-Fishery
01 Day Care 17 Grade 7 23 1st Year PS/N-T/TV 52 ALS Secondary 1 Accountancy, Business, and 7 Industrial Arts
02 Kindergarten/ 18 Grade 8 24 2nd Year PS/N-T/TV
19 Grade 9 53 SPED Elementary Management 8 Information and Communications
Preparatory 210 Post secondary 54 SPED Secondary Technology or ICT
20 Grade 10 2 Science, Technology, Engineering,
graduate, specify course 500 SPED Graduate 9 Sports
and Mathematics
SENIOR HIGH SCHOOL 3 Humanities and Social Sciences 10 Arts and Design
GRADE SCHOOL 21 Grade 11 COLLEGE MASTERS/PHD 4 General Academic
11 Grade I 22 Grade 12 31 1st Year College 41 Post Grad w/ units 5 Home Economics
12 Grade II 200 High school graduate 32 2nd Year College 400 Masters/PhD
13 Grade III (Old curriculum) 33 3rd Year College graduate, specify course
14 Grade IV 201 Senior High school 34 4th Year College or
15 Grade V graduate (K-12 curriculum) higher
16 Grade VI 300 College graduate,
100 Elementary specify course
graduate

CBMS Form 1 PAGE 3

 HCN: _________

F. ECONOMIC ACTIVITY
TO BE ASKED TO ALL MEMBERS INCLUDING OFWs TO BE ASKED TO NON-OFW MEMBERS ONLY
(34) (35) (36) (37) (38) (39) (40) (41) (42)
IF YES IN (34) OR YES IN (35)
FOR 15 YEARS OLD AND
ABOVE
What was ___’s primary occupation
In what kind of industry did __
during the past week?
Did ___ do any work during the past week?
Although __ did
work for at What was __'s
not work, did __ How many What was __'s total
least 1 hour What is __'s normal working
N have a job or work, jobs or number of hours
U
during the past nature of hours per day Did __ want more
business during businesses worked during the
M week? employment? during the past hours of work during
the past week? does __ have? (SPECIFY INDUSTRY, E.G. past week?
B (SPECIFY OCCUPATION, E.G. week? the past week?
PRIMARY/ELEMENTARY
E ELEMENTARY TEACHER, RICE
EDUCATION, GROWING PADDY
R FARMER, ETC.)
RICE, ETC.)

1. Yes (GO TO 1. Yes

(36)) PRIMARY JOB,
CODE
BUSINESS/
CODE
(SEE CODES NUMBER OF TOTAL NUMBER OF 1. Yes
2. No (GO TO (45)) OCCUPATION, OR BUSINESS INDUSTRY BELOW) HOURS HOURS
2. No
2. No

10

(39) Nature of Employment

1 Permanent job/business/unpaid family work

2 Short-term or seasonal or casual job/business/unpaid family work
3 Worked for different employers or customers on day-to-day or week-to-week basis

CBMS Form 1 PAGE 4

 HCN: _________

(43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58)
FOR 15 YEARS OLD AND ABOVE FOR 5 YEARS OLD AND ABOVE FOR 18 YEARS OLD AND ABOVE IF YES IN (56) IF NO IN (56)

IF YES IN (34) OR YES IN IF NO IN (34) AND NO IN (35)

(35) Did ___ IF YES IN (45) IF NO IN (45)
look for In the past 12 months, how
Was this much total salary/wages did
work or try __'s first
to Had Was ___ ____ receive?
time to
establish How opportunity willing to Is _____ a
Did __ look for What
business many Why for work take up
look for work or has ___ When was the existed last Is ___ a Is ___ a Is ___ a What is _____'s dependent
N during the weeks did __ work member of
additional What is try to been last time ___ member member membership of a
past has __ not look week or during the PhilHealth
U work __'s class establish doing to looked for of SSS? of GSIS? type? PhilHealth
week? been for within two past week ?
M a DO NOT INCLUDE SALARY OF
during the of worker? find work? weeks, would or within 2 member?
B
past business? work? looking work? HOUSEHOLD MEMBERS WHO
E for __ been weeks? ARE OFW AND
week? available? HOUSEMAIDS/BOYS
R work?

1. Yes
1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes
(SEE (SEE
(SEE CODES GO TO (SEE CODES
2. No 2. No (GO 2. No CODES CODES 2. No 2. No (A) CASH (B) IN KIND 2. No 2. No 2. No 2. No
BELOW) (51) BELOW)
BELOW)
TO (49)) BELOW)

10

(47) Job search method (49) Reason for not looking for work
(44) Class of worker
(50) Last time looked (58) PhilHealth Membership Type
1 Registered in public employment agency 1 Tired/Believes no work is available for work
1 Working for private household 7 Household, family 1 PhilHealth - OFW
2 Working for private business/establishment/farm 2 Registered in private employment agency 2 Awaiting results of previous job application 2 PhilHealth - Employed
3 Working for government/government corporation duties 1 Within last month 3 PhilHealth - Individually-paying
4 Self-employed with no paid employee 3 Approached employer directly job application 4 PhilHealth - Sponsored
5 Employer in own family-operated farm or business 8 Schooling 2 One to six months 5 PhilHealth - Lifetime
6 Working with pay on own family operated farm 4 Approached relatives or friends 3 Temporary illness/ disability 6 PhilHealth - Senior Citizen
or business 9 Others, specify 3 More than six 7 PhilHealth - Indigent
7 Working without pay on own family-operated farm 5 Placed or answered 4 Bad weather
or business months
advertisements 5 Waiting for rehire/
4 Never
6 Searched and applied online
6 Too young/old or retired/permanent
7 Others, specify
disability

CBMS Form 1 PAGE 5

 HCN: _________

G. OTHER CHARACTERISTICS OF HOUSEHOLD MEMBERS H. CRIME I. HEALTH AND NUTRITION

(59) (60) (61) #N/A (63) (64) (65) (66) (67) (68) (69) (70) (71) (72)
IF YES IN FOR 60 IF '1', '2', '3' OR
IF CODE 2 IF YES IN (62) IF YES IN (66) FOR 5 YEARS OLD AND BELOW
(60) YEARS OLD '4' IN (69)
Is __ a
IN (12) Does__
AND ABOVE Has
solo have
___been a What is
N parent any What type What
Does ___ Does __ Does __ victim of Where ___'s What is the
U taking physical of crime/s DATE OF RECORD
have a have a have a crime in did the blood Rhesus (Rh) NUTRITIONAL
OF BARANGAY
M Is __ care of a or disability Senior the past 12 was/were crime type? factor of ____'s STATUS OF
child/ Solo mental PWD NUTRITION
B pregnant? does __ __ a CHILDREN 0-5
E children? Parent disability? have? ID? Citizen’s months? happen? blood type? YEARS OLD
SCHOLARS
ID? ID? victim of?
R

1. Yes 1. Yes 1. Yes 1. Yes (SEE 1. Yes 1. Yes 1. Yes

(SEE CODES (SEE CODES (SEE CODES TO BE FILLED BY FIELD COORDINATOR (SEE
CODES (SEE CODES BELOW)
2. No (GO 2. No (GO TO BELOW) BELOW) BELOW) CODES BELOW)
2. No 2. No 2. No BELOW) 2. No 2. No
TO (65)) (69))

10

(63) Type of Disability (67) Crime (68) Location of Crime (69) Blood type (70) Rh Factor (71) Nutritional Status
1 Mental/Intellectual 6 Disability due to Chronic illness 1 Theft
1 O 1 Positive 1 Overweight
1 Within the 2 A
2 Hearing Disability 7 Orthopedic (Musculoskeletal) 2 Robbery
3 Psychosocial Disability barangay 3 B 2 Negative 2 Normal
Disability 3 Rape 2 Outside the
4 Visual Disability 8 Multiple Disabilities, specify ____ 4 AB 3 Don’t Know
5 Speech Impairment 9 Learning Disability 4 Physical injury barangay but within 3 Underweight
municipality/city 5 Don't Know
5 Carnapping 4 Severely underweight
6 Cattle rustling 3 Outside the
municipality/city but
7 Others, specify within province
4 Outside the

CBMS Form 1 PAGE 6

 HCN: _________
I. HEALTH AND NUTRITION (80) What is the household's main source of cooking fuel?

(73) During the past 12 months, did you or any member of the 1 Electricity 5 Kerosene 7 Animal dung
household avail of medical treatment for any illness? 2 LPG 6 Agricultural crops 8 Straws/Shrubs/Grass
1 Yes (GO TO 74) 3 Charcoal/Coal residues (e.g. coconut midribs, 9 Others, specify
2 No 4 Wood coconut shells, coconut/corn husks, rice hulls, etc.)
3 Did not get sick (81) Is there any electricity in the dwelling place?
1 Yes (GO TO 82)
During the last illness of any member of the household, 2 No (GO TO 83)
(74)
where did you go to avail medical treatment? 1. Yes
(82) What is the source of electricity in the dwelling place?
1 Public hospital (National) 6 Rural health units 2. No
2 Public hospital (Provincial) 7 Barangay Health Station 1 Electric company
3 Public hospital (Municipal/City) 8 Non-medical/non-trained 2 Generator
3 Solar
4 Public hospital (District) Hilot/Personnel
5 Private hospital/clinic 9 Others, specify ______ 4 Battery
5 Others, specify _______________
J. WATER AND SANITATION Does any member of the
Do you own any of the (84) How
(83) (85) household have access to
(75) What is your household's main source of water supply? following? many were internet ?
acquired in the
1 Own use faucet, community water system (e.g. Maynilad ) 1. Yes (GO TO 84) past 3 years? 1. Yes
2 Shared faucet, community water system 2. No (GO TO 85) 2. No
3 Own use tubed/piped deep well
(87) Who is
4 Shared tubed/piped deep well 1 Land (Agricultural, the insurance
Do you have
1. Yes provider?
5 Tubed/piped shallow well (e.g. Poso, Artesian well, etc.) in parcels) (86) insurance for the
2. No
following?
6 Dug well (e.g. balon) 2 Land (Residential,
(see codes below)
7 Protected spring in parcels)
8 Unprotected spring 3 Land (Commercial, 1 House
9 Lake, river, rain, and others in parcels) 2 Motor vehicle
10 Peddler 4 Car, jeep, van 3 Appliances
11 Bottled water (purified, distilled, mineral) 5 Tricycle, motorcycle, (87) Insurance Provider
ASK (76) IF ANSWER IN (75) IS '2', '3', '4', '5', '6' , '7', '8', OR '9'. IF THE e-bike 1 Government insurance
ANSWER IN (75) IS '1', '10 or '11', GO TO (77). 6 Bicycle 2 Private insurance company
How far is this water source from your house? 7 Pedicab 3 Bank
(76)
IN METERS 8 Television 4 Others, specify
9 Radio/Radio casette L. WASTE MANAGEMENT
(77) What type of toilet facility does the household use?
10 CD/VCD/DVD player
1 Water-sealed, sewer septic tank, used exclusively by 11 Component/Stereo/ What is the system of 1. Yes
household Karaoke/Videoke (88) garbage disposal adopted 2. No
by the household?
2 Water-sealed, sewer septic tank, shared with other
12 Cellphone
households
13 Landline telephone 1 Garbage collection
3 Water-sealed, other depository, used exclusively by 14 Computer/Laptop/ 2 Burning
household Netbook 3 Composting
4 Water-sealed, other depository, shared with other 15 Electric fan 4 Recycling
households 16 Airconditioner/air 5 Waste segregation
5 Closed pit cooler
6 Pit with cover
6 Open pit 17 Electric iron/steamer 7 Pit without cover
7 Pail system 18 Washing machine Throwing of garbage
8
8 None (bodies of water, backyard, public spaces) 19 Refrigerator/Freezer in river, vacant lot, etc.
K. HOUSING 20 LPG gas 9 Others, specify
What is the tenure status of the housing unit and lot stove/electric ASK QUESTIONS (89) AND (90) IF CODE 1
(78) stove/range
occupied by your household? IN (88.1)
1 Own or owner-like possession of house and lot 21 Rice cooker Who collects the
(89)
22 Microwave oven garbage?
2 Rent house/room including lot
23 Toaster/Toaster oven 1 Municipal/city collector
3 Own house, rent lot 24 Electric water 2 Barangay collector
dispenser
4 Own house, rent-free lot with consent of owner
3 Private collector
5 Own house, rent-free lot without consent of owner 25 Sala/Sofa set
4 Others, specify

6 Rent-free house and lot with consent of owner 26 Sleeping mats

(banig )
7 Rent-free house and lot without consent of owner How often is the garbage
(90)
8 Living in a public space with rent 27 Frame without collected?
9 Living in a public space without rent mattress (papag, 1 Daily
folding bed)
2 Thrice a week
ASK (79) IF ANSWER IN (78) IS '1', '3', '4', '5', '6' , '7' OR '9'. IF THE 28 Mattress (kutson ,
3 Twice a week
ANSWER IS '3,' ASK ONLY FOR THE IMPUTED RENT FOR THE sofa bed)
HOUSE. IF THE ANSWER IN (78) IS '2' OR '8,' GO TO (80). 4 Once a week
(79) By your own estimate, how much is the imputed rent per 29 Others, specify ____ 5 Others, specify
month for the house and/or lot?

CBMS Form 1 PAGE 7

M. SOURCES OF INCOME
NET INCOME
M.1. ENTREPRENEURIAL ACTIVITIES/SUSTENANCE ACTIVITIES
(A) (B)
During the past 12 months, did you or any member of your household operate in any of the following What was the total net value of income from these activities
entrepreneurial activities? 1 - Yes during the past 12 months? (in pesos)
2 - No
ENTREPRENEURIAL ACTIVITIES/SUSTENANCE ACTIVITIES (A) IN CASH (B) IN KIND
CROP FARMING AND GARDENING such as growing of palay, corn, roots and tubers, 91A 91B
(91)
vegetables, fruits, nuts, orchids, ornamental plants, etc.
LIVESTOCK AND POULTRY RAISING such as raising of carabaos, cattle, hogs, horses, 92A 92B
(92)
chicken, ducks, etc., and the production of fresh milk, eggs, etc.
FISHING such as capturing fish (with a boat of three tons or less); gathering of fry, shells, 93A 93B
(93)
seaweeds, etc.; and culturing fish, oysters, mussel, etc.
FORESTRY AND HUNTING such as tree planting (ipil-ipil), firewood gathering, small-scale
94A 94B
(94) logging (excluding concessionnaires), charcoal making, forestry product gathering (cogon,
nipa, rattan, bamboo, resin, gum, etc.) or wild animals/birds hunting
95A 95B
(95) WHOLESALE AND RETAIL including market vending, sidewalk vending, and peddling

MANUFACTURING such as mat weaving, tailoring, dressmaking, bagoong making, fish 96A 96B
(96)
drying, etc.
COMMUNITY, SOCIAL, RECREATIONAL, AND PERSONAL SERVICES such as medical 97A 97B
(97)
and dental practice, practice of trade, operation of schools, restaurants and hotels, etc.
TRANSPORTATION, STORAGE AND COMMUNICATION SERVICES such as jeepney or 98A 98B
(98)
taxi operations, storage and warehousing activities, messengerial services, etc.
MINING AND QUARRYING such as mineral extraction like salt making, gold mining, gravel, 99A 99B
(99)
sand and stone quarrying, etc.
100A 100B
(100) CONSTRUCTION like repair of a house, building, or any structure

ACTIVITIES NOT ELSEWHERE CLASSIFIED including electricity, gas and water; financial, 101A 101B
(101)
insurance, real estate, and business services
(102A): Add the net income from (102B): Add the net income from
(91A) to (101A) (91B) to (101B)
(102) TOTAL NET INCOME FROM ENTREPRENEURIAL ACTIVITIES
102A 102B

M.2 SALARIES AND WAGES FROM EMPLOYED MEMBERS

(103A): Add all salaries/wages of (103B): Add all salaries/wages of
(103) TOTAL SALARIES AND WAGES all members in cash in Question all members in kind in Question
(53)A (53)B

103A 103B

M.3. OTHER SOURCES OF INCOME

GROSS INCOME
During the past 12 months, how much did you or any member of your household receive from the following?
(A) IN CASH (B) IN KIND
104A 104B
(104) Remittances from Overseas Filipino Workers

105A 105B
(105) Cash receipts, gifts, support, relief, and other forms of assistance from abroad

106A 106B
(106) Cash receipts, support, assistance, and relief from domestic sources

107A 107B
(107) Pension and retirement, workmen's compensation, and social security benefits

Net share of crops, fruits, and vegetables produced, aquaculture products harvested or livestock and 108A 108B
(108)
poultry raised by other households
109A 109B
(109) Rentals received from non-agricultural lands, buildings, spaces, and other properties

110A 110B
(110) Interest from bank deposits, interest from loans extended to other families.

111A 111B
(111) Dividends from investments

112A 112B
(112) Other sources of income not elsewhere classified

(113A): Add income from (104A) (113B): Add income from (104B)
(113) TOTAL INCOME FROM OTHER SOURCES OF INCOME to (112A) to (112B)

114B: Get the monthly imputed

(114) TOTAL IMPUTED RENT FROM OWNED OR RENT-FREE HOUSE AND/OR LOT
rent from (79) and multiply by 12

(115B) = 102B+ 103B+ 113B

(115A) = 102A + 103A + 113A
+114B
(115) TOTAL INCOME IN CASH AND IN KIND

(116) TOTAL HOUSEHOLD INCOME 116= (115A) + (115B)

CBMS Form 1 PAGE 8

 HCN: ____

N. AGRICULTURE-FARMING P. AGRICULTURE-FISHING
ASK QUESTIONS (117)-(122) IF CODE '1' IN (91). IF CODE '2' IN (91), ASK QUESTIONS (125)-(133) IF CODE '1' IN (93). IF CODE '2' IN (93), GO TO
GO TO (123). (134)
(117) What is the tenure status of the agricultural land being (125) Is the household engaged in the following? 1-Yes 2-No
tilled by the household? 1 Catching /gathering fishes, crabs, shrimps, etc.
1 Fully-owned 7 Held under Certificate of 2 Culturing fish, seaweeds, etc.
2 Owner-like possession Ancestral Domain Title/ Certificate ASK QUESTIONS (126)-(130) IF CODE 1 IN 125.1
3 Tenanted of Ancestral Land Title (CADT/CALT) (126) Where did household/s member/s fish in the
4 Leased/Rented 8 Held under Community-Based past 12 months?

5 Rent Free Forest Management Agreement 1 Marine waters

6 Held under Certificate of Land (CBFMA)/ Stewardship 2 Inland waters
Transfer (CLT) or Certificate of 9 Others, specify
3 Both
Land Ownership Award (CLOA)
(127) How many of each of the following types of (128) How many
boats/vessels does the household use in fishing boats/vessels does the
(118) What is the area of the agricultural land?
activities? household own?
(in hectares) (Number)
(Number)
1 Boat with engine and outrigger
(119) (120) 2 Boat with engine but without outrigger
During the past 12 months, 3 Boat without engine but with outrigger
During the past 12 months, what temporary and
how much did you harvest? 4 Boat without engine and outrigger
permanent crops did your household harvest?
(in kilograms) 5 Raft
1 (129) (130)
2 What kind of gears/accessories/devices How many does the
was/were used? household own?
3
4 KIND Number
5 1
(121) (122) 2
How many of each of the folllowing How many agricultural 3
agricultural equipment/facilities does equipment/facilities does
the household use? Number the household own? 4
Number ASK QUESTION (131) IF CODE 1 IN 125.2
1 Beast of burden (e.g. carabao) (131) What type of aquafarm did the household
operate? 1- Yes 2- No
2 Plow
3 Harrow 1 Fishpond
4 Mower 2 Fish pen
5 Thresher/Corn sheller 3 Fish cage
6 Insecticide/Pesticide sprayer 4 Seaweed farm
7 Farm tractor 5 Oyster farm
8 Hand tractor 6 Mussel farm
9 Turtle/Mudboat 7 Fish tank
10 Planter/Transplanter/Dryer 8 Hatchery
11 Mechanical dryer 9 Others, specify
12 Multipurpose drying pavement (132) (133)
13 Rice/corn/feed mill For the past 12 months, what were the fishes or aquatic How much was the
14 Harvester, any crop animals cultured or caught by your household? volume of fish
harvested/caught in the
15 Warehouse granary past 12 months?
16 Farmshed (in kilograms)
17 Irrigation pump 1
18 Others, specify 2
3
O. AGRICULTURE-LIVESTOCK AND/OR POULTRY RAISING 4
ASK QUESTIONS (123)–(124) IF CODE '1' IN (92). IF CODE '2' IN (92), 5
GO TO (125). Q. CLIMATE CHANGE AND DISASTER RISK MANAGEMENT
(123) (124) (134) How many years has the household been living in the
For the past 12 months, what types of livestock a) Volume of b) Volume of barangay?
production production
and/or poultry animals were raised and provided sold consumed 1. 3 years and above (GO TO 135)
the following products?
Type of livestock/poultry 2. Not more than 3 years (GO TO 167)
(SEE CODES BELOW) Number

1 Live animals Q.1. CROP FARMING

(number of heads) ASK QUESTIONS (135)-(141) IF CODE '1' IN (91) AND CODE '1' IN 134
2 Meat (135) How many years has the household been engaged in
(weight in kilograms) crop farming?
3 Milk 1. 3 years and above (GO TO 136)
(in liters) 2. Not more than 3 years (GO TO 142)
4 Eggs
(number) (136) Compared with 3 years ago, did your harvest ___?
5 Others, specify 1. Decrease (GO TO 137)
2. Increase (GO TO 140)
(123) 1-Hog/Swine 2-Goat 3-Carabao 4-Cattle 5-Chicken 6-Duck 7-Others, specify
3. Remain the same (GO TO 140)

CBMS Form 1 PAGE 9

 HCN: ___________
(137) What is the primary reason for the decrease in total harvest? Q.4. TEMPERATURE
1. Increase in cost of inputs such 6. Decrease in supply of water (152) Compared with 3 years ago, is the temperature
as fertilizer, pesticides, etc. from the irrigation system hotter now in your area?
2. Affected by drought 7. Decrease in land area 1. Yes
3. Affected by typhoon 8. Change in primary occupation 2. No
4. Affected by flood of member Q.5. ELECTRICITY
5. Affected by pests 9. Others, specify (153) Compared with 3 years ago, are brownouts more
(138) During the past 3 years, did you do the following in the 1 - Yes (139) Reasons frequent now in your area?
last planting season? 2 - No (see codes below) 1. Yes
138.1 Changed the variety of the same crop 2. No
138.2 Changed major crop Q.6. SEA LEVEL
(140) Do you have an insurance for the following: (141) Who is the
1 - Yes insurance provider? (154) Compared with 3 years ago, did the sea level
2 - No (see codes below) ___ in your area?
140.1 Crops 1 Decrease 4 Don't know
140.1 Agricultural equipment/ facilities 2 Increase 5 Not applicable
Q.2. LIVESTOCK AND POULTRY 3 Remain the same
ASK QUESTIONS (142)–(146) IF CODE '1' IN (92) AND CODE '1' IN 134 Q.7. WATER SUPPLY
(142) How many years has the household been (155) Compared with 3 years ago, did the water supply
engaged in livestock and poultry raising? ____ in your area?
1. 3 years and above (GO TO 143) 1. Decrease (GO TO 156)
2. Not more than 3 years (GO TO 145) 2. Increase (GO TO 157)
(143) Compared with 3 years ago, did the number of your livestock and poultry __? 3. Remain the same (GO TO 157)
1. Decrease (GO TO 144) (156) What is the primary reason for the decrease
2. Increase (GO TO 145) in water supply?
3. Remain the same (GO TO 145) 1. Drought
(144) What is the primary reason for the decrease in number of livestock 2. Broken faucet/pump
and poultry? 3. Lower water level in the dam
1. Increase in cost of farm inputs (feeds, chicks, etc.) 4. Less frequent delivery of tanker truck/peddler
2. Stricken with diseases (swine flu, bird flu, foot and mouth 5. Increase in number of consumers
disease, etc. ) 6. Others, specify
3. Decrease in land holding Q.8. FLOODING
4. Affected by typhoon (157) Compared with 3 years ago, do floods occur
5. Affected by flood more often in your area now?
6. Affected by extreme hot weather condition 1. Yes (GO TO 158)
7. Others, specify 2. No (GO TO 160)
(145) Do you have livestock and poultry insurance? 3. Did not experience flood (GO TO 160)
1. Yes (GO TO 146) (158) Three years ago, how long did it usually take
2. No (GO TO 147) for the flood to subside?
(146) Who is the insurance provider? (Specify the number of hours)
(SEE CODES BELOW) (159) During the past 12 months, how long did it
Q.3. FISHING usually take for the flood to subside?
ASK QUESTIONS (147)-(151) IF CODE '1' IN (93) AND CODE '1'IN 134 (Specify the number of hours)
(147) How many years has the household been Q.9. DROUGHT
engaged in fishing? (160) Compared with 3 years ago, does drought
1. 3 years and above (GO TO 148) occur more often in your area now?
2. Not more than 3 years (GO TO 152) 1. Yes (GO TO 161)
(148) Compared with 3 years ago, did your fish catch ___ ? 2. No (GO TO 162)
1. Decrease (GO TO 149) 3. Did not experience drought (GO TO 162)
2. Increase (GO TO 150) (161) In the past 3 years, how long did the last drought occur?
3. Remain the same (GO TO 150) IN MONTHS
(149) What is the primary reason for the decrease in fish catch?
1. Decrease in fishing area due to government restrictions
2. Decrease in fishing area due to competition Q.10. EVACUATION
3. Decrease in fishes (162) During the past 3 years, did you move out/leave
4. Occurrence of coral bleaching permanently from your previous dwelling unit?
5. Occurrence of fishkill 1. Yes (GO TO 163)
6. Occurrence of oil spill and other kinds of pollution 2. No (GO TO 164)
7. Less frequent fishing because of increase in fuel (163) What was your primary reason for moving out/evacuating
prices and other expenses from your previous dwelling unit?
8. Frequent occurrence of typhoons (SEE CODES BELOW)
9. Others, specify (164) During the past 3 years, did you temporarily
(150) Do you have fisheries insurance? evacuate your house because of any calamity?
1. Yes (GO TO 151) 1. Yes (GO TO 165)
2. No (GO TO 152) 2. No (GO TO 167)
(151) Who is the insurance provider? (165) During your last temporary evacuation, where did you stay?
(SEE CODES BELOW) (SEE CODES BELOW)

(139) Reasons
Reason for changing crop (166) How long did you stay in the evacuation area? (in days)
1. The inputs to the former crop are more expensive (163) Primary reason for moving out/ leaving permanently
2. The present crop is more resistant to pests and diseases 1. Typhoon 5. Volcanic eruption 8. Fire 11. Infrastructure
3. The present crop does not require much water 2. Flood 6. Landslide or 9. Forest fire development project
4. The present crop enables the member to earn more profit 3. Drought mudslide 10. Armed conflict 12. Others, specify
5. The seedling of the former crop is no longer available 4. Earthquake 7. Tsunami
6. Others, specify (165) Evacuation areas
(141), (146), (151) 1. School 4. Relative's house 6. Barangay/City hall 9. Others, specify
1 - Philippine Crop Insurance Corporation 3 - Bank 2. Church 5. Neighbor or 7. Multi-purpose hall
2 - Private insurance company 4 - Others, specify 3. Covered court/gym friend's house 8. Designated evacuation centers

CBMS Form 1 PAGE 10

 HCN: _________
Q.11. CALAMITY R. HUNGER
(167) (168) (169) (170) (174) In the last 3 months, did it happen even once
During the past 12 months, IF YES IN (167) that your household experienced hunger and
which of the following How many Did you IF YES IN (169) did not have anything to eat?
calamities affected your times did receive any
kind of
Where did it 1 Yes (GO TO 175)
household: the __
1-Yes assistance? come from? 2 No (GO TO 177)
happen?
2-No (SEE CODES
BELOW, MULTIPLE
1-Yes 2-No RESPONSES
During the past 3 months, how
(175) (176)
ALLOWED)
many days did your household
1. Typhoon experience hunger and not have
anything to eat? NUMBER OF
2. Flood NAME OF MONTH
DAYS
3. Drought
4. Earthquake a. First Month
5. Volcanic eruption
6. Landslide/mudslide b. Second Month
7. Tsunami
8. Fire c. Third Month
9. Forest fire
10. Armed conflict S. DEATH
(177) Were there any household members who died in
11. Others, specify _____________
the past 12 months?
(170) Assistance provider 1 Yes (GO TO 178)
1. National government 3. Non-government organization 5. Relatives 2 No (GO TO 182)
2. Local government 4. International organization 6. Others, specify IF YES IN (177)
Q.12. DISASTER PREPAREDNESS (178) (179) (180) (181)
(171) Do you have a disaster preparedness kit? What is the name of the person What is __'s What was What was
1. Yes (GO TO 172) who died? sex? __'s age the cause
2. No (GO TO 174) at the of __'s
time of death?
(172) (173)
death?
Do you have the following in your disaster 1 - Yes How many days
preparedness kit? 2 - No will it last? 1 - Male (SEE CODES
NAME 2 - Female
AGE BELOW)
1. Water
2. Food (canned goods, biscuits, bread)
1
3. Matches/Lighter
4. Flashlight/Emergency light
2
5. Radio/Transistor (battery-operated)
6. Candle
3
7. Medical kit
8. Whistle (181) Cause of death
1. Diseases of the heart (e.g. 7. Tuberculosis 12. Drowned from
9. Clothes heart attack) 8. Chronic lower respiratory flood/storm surges/tsunami
2. Diseases of the vascular diseases (e.g. COPD, bronchitis, 13. Victim of landslide
10. Blanket 14. Electrocuted during
system (e.g. stroke) asthma)
11. Battery (cellphone, flashlight, radio, etc.) 3. Malignant neoplasms (e.g. 9. Diabetes mellitus typhoon or storm surge
cancer) 10. Nephritis, nephrotic 15. Murder
12. Important documents (land title, valid ID 4. Pneumonia syndrome and nephrosis (e.g. 16. Others, specify
5. Road/ Vehicular accidents inflammation of the kidney)
birth certificate, etc.) 6. Other accidents 11. Certain conditions originating
in the perinatal period
13. Others, specify
T. PROGRAMS
(182) IF YES IN (182)
During the past 12 months, did you or any member of your (183) (184) (185) (186)
household receive or avail of any of the following programs? How many What is/are the name/s of the
household Who
What is the name of the household member/s who
members are implemented
program? is/are beneficiary/ies
covered by or
/members of the program? this program?
are members of
1 - Yes FULL NAME OF this program? NAME OF HOUSEHOLD (SEE CODES
TYPE OF PROGRAM
2 - No PROGRAM MEMBER/S BELOW)

1. Sustainable Livelihood Program (DSWD)

2. Food for Work

3. Cash for Work

4. Social Pension for the Indigent Senior Citizens

(186) Program Implementer 1 - National 3 - City/Municipality 5 - Congress/District 7 - Don't know

2 - Province 4 - Barangay 6 - Private Organizations/NGOs 8 - Others, specify

CBMS Form 1 PAGE 11

 HCN: _________
T. PROGRAMS
182 IF YES IN (182)
(183) (184) (185) (186)

During the past 12 months, did you or any member What is/are the name/s of the
of your household receive or avail of any of the What is the name of the How many household member of the household who Who implemented this
following programs? program? member/s are is/are beneficiary/ies/ program?
covered by or members of the program?
members of this
program?
1 - Yes NAME OF HOUSEHOLD
TYPE OF PROGRAM FULL NAME OF PROGRAM (SEE CODES BELOW)
2 - No MEMBER/S

5. Pantawid Pamilyang Pilipino Program

(4Ps)

6. Agrarian Reform Community

Development Program (ARCDP)

7. Training for Work Scholarship

Program (TWSP)

8. Community-Based Employment
Program (CBEP)

9. Other health insurance (Maxicare, 1.

Medicare, Intellicare, etc.)
2

1.
10. Health assistance

2.

1.
11. Supplemental feeding

2.

1.
12. Education/scholarship program

2.

1.
13. Skills or livelihood training program

2.

1.
14. Credit program

2.

1.
15. Housing program

2.

1.

16. Other programs, specify

2.

3.
(186) Program Implementer 1 - National 5 - Congress/District
2 - Province 6 - Private Organizations/NGOs
3 - City/Municipality 7 - Don't know
4 - Barangay 8 - Others, specify

CBMS Form 1 PAGE 12