Survey form

ENVIRONMENTAL HEALTH & SANITATION

Municipality: _______ Barangay:______________ Date:________

Total no, of population: ____ Total no of household:____

Type of water source (Baranggay); level 1 ___ level 2 ____ level 3_____

Total no. of HH using purified/distilled water:____

Total no. of HH with sanitary toilet facility:____ Total no. of HH with unsanitary toilets:_____

Total no. of HH with no toilet:_____

Total no. of HH with waste segregation:____ with backyard composting:_____

Waste collected by garbage truck:_____ waste burying/burning:______

Submitted by:_________________________