BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos

COMMUNITY SURVEY TOOL

(NEED ASSESSMENT)
Control No. Number of Family: ______________
st
Address: Date: 1 visit _______________
nd
Informant: 2 visit _______________
rd
Surveyed by: 3 visit _______________
Time Started:__________________ Time Finished: __________________ Status of last visit:_______________

I. Demographic Variable

OCCUPATION L
BIRTHDATE E
Type Place of Work N
M G
A P
L T
R
I
R A H
G T E I
HIGHEST C
RELATION E A L f C O
-SHIP TO A EDUCATIONAL L E
N L I S E A F
# NAME OF FAMILY MEMBER THE HEAD G COMPLETED (3 O
OF THE D
E G YEARS OLD
T M T R
E S C O
FAMILY I AND ABOVE) A P E E
R M D Y T A F
O T L G S
A TI
N U O O I
T O O
U S Y R D
N R
S E Y E
I
D N
G
C
I
N E

LEGEND:
Gender: Marital Status: Religion: Education:
1- Male 1- Child 1- Roman Catholic 1- Pre- elem. 8- College Level
2- Female 2- Single 2- Muslim 2- Elem. Level 9- College Grad.
3- Married 3- Iglesia ni Cristo 3- Elem. Grad. 10- Post- Grad.
4- Married but Separated 4- Born Again Christian 4- High School Level 11- Over 7 years
5- Widow 5- Jehova’s Witness 5- High School Grad old w/o formal
6- Widower 6-Protestant (Methodist; 6- Vocational schooling
Evangelical; Baptist; Adventist) 7- Short Course 12- <5 yeas old
7-others: ___________________ 13- SPED
TYPE OF WORK:

STATUS:
1 - Employed Place of Work:
1- Regular Full-time Location: Category: Place of Origin:
2- Regular Part- time 1- with in the community 1- In-House 1- Metro Manila
3- Contractual 6 months 2- with in the municipality/city 2- Field 2- Central Luzon
4- Contractual every week 3- outside the municipality/city 3- Office 3- Northern Luzon
5- Contractual everyday 4- OFW- outside the country 4- Southern Luzon
6- Self- Employed 5- Visayas Region
7- Seasonal 6- Mindanao Region
8- OFW
9- Contractual by job offer

2 – Unemployed (and other conditions such as: Senior, PWD, Retired and/or with Health condition)
3 – Minor (below majority of age 18y.o.)

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 a. Type of Family:

Based on composition:
( ) Nuclear ( ) Extended ( ) Dyad ( ) Single- parent ( ) Homosexual/Same Sex ( ) Cohabiting/Communal
Based on locus of power
( ) Patrifocal/Patriarchal ( ) Matrifocal/Matriarchal ( ) Egalitarian ( ) Matricentric
Based on place of residence
( ) Patrilocal ( ) Matrilocal ( ) Bilocal (Ambilocal) ( ) Neolocal
Based on descent
( ) Patrilineal ( ) Matrilineal ( ) Bilateral
b. Dialect Frequently used: ______________________________________________

II. Socio- economic, cultural and environmental (Multiple Response)

1. Social Indicators

A. Services in the Community: ( ) Religious services ( ) Livelihood Services ( ) livelihood service

( ) Health Services ( ) Garbage collection ( ) Peace and Order
B. Institutional Facilities: ( ) Brgy. Hall ( ) Health Station ( ) Church ( ) School
C. Organizations: ( ) Senior Citizen ( ) Youth ( ) Others __________
D. Tradition/Customs: ( ) Bayanihan ( ) Palabra de Honor ( ) Pakikisama ( ) Ningas Kugon
( ) Fiestas ( ) Close family ties ( ) Respect for elderly
( ) Others____________
E. Recreational Facilities: ( ) Volleyball/Basketball court ( ) Playground ( ) Plaza ( ) Others_______________
F. Mode of Transportation: ( ) Tricycle ( ) Jeep ( ) PUJ/PUV ( ) Bicycle ( ) Private vehicle
G. Mode of Communication: ( ) Postal system ( ) Internet ( ) Telephone ( ) Cell phone
( ) Two- way radio ( ) Others, specify: ____________

2. Economic Indicator:

A. How many Income earners per family(ies)? Earner 1 : Family position:______________ Php __________
Earner 2 : Family position:______________ Php __________
Earner 3 : Family position:______________ Php __________
Earner 4 : Family position:______________ Php __________

B. Monthly Family Income (combined)

( ) less than 5,000 ( ) 25,001- 30,000 ( ) 50,001 and above
( ) 5,001- 10,000 ( ) 30,001- 35,000
( ) 10,001- 15,000 ( ) 35,001- 40,000
( ) 15,001- 20,000 ( ) 40,001- 45,000
( ) 20,001- 25,000 ( ) 45,001- 50,000

C. Financial Source for Family expenditures:

( ) Employment ( ) Business ( ) Pension ( ) Help from relative/friends ( ) Others:
D. Monthly Family Expenditures:
( ) less than 5,000 ( ) 25,001- 30,000 ( ) 50,001 and above
( ) 5,001- 10,000 ( ) 30,001- 35,000
( ) 10,001- 15,000 ( ) 35,001- 40,000
( ) 15,001- 20,000 ( ) 40,001- 45,000
( ) 20,001- 25,000 ( ) 45,001- 50,000
E. Priorities and Expenditure ( family’s priority by ranking 1-7 where 1 is the highest priority)
( ) Food ( ) Clothing ( ) Education ( ) Utilities
( ) Health ( ) Recreation ( ) Savings
F. Adequacy of Family Income:
( ) Adequate ( ) Not Adequate

3. Cultural Indicator:

A. Cultural Orientation regarding Illness (Multiple Response)

( ) believe that illness is caused by physiologic factor e. g. infection
( ) believe that illness is caused by supernatural phenomenon e. g. kulam, balis
( ) believe that illness is a punishment from GOD
( ) believe that illness is caused by other person
( ) believe that illness is caused by change in weather
( ) others:_______________

B. Cultural Belief: (Multiple Response)

( ) health can be restored by GOD/ other spiritual faith
( ) health can be restored by faith healers
( ) health can be restored by supernatural power e.g. Tawas, hilot, hula
( ) health can be restored by health personnel e. g. doctors, nurses

C. Cultural Perception
( ) always practices local cultural practices about health matters
( ) sometimes practices local cultural practices about health matters
( ) does not practice any local cultural practices about health matters

D. Community Involvement

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 ( ) Actively join fiesta, religious procession, local cultural practices ( ) does not actively join

4. Environmental Indicator

A. Home
a. Ownership: ( ) Owned ( ) Rented ( ) Rent- free ( ) Least to own
( ) squatting/informal settlers ( ) professional squatters
b. Construction materials used: ( ) Light ( ) Mixed ( ) Strong (Concrete)
c. Number of rooms used for sleeping:( )1 ()2 ()3 ()4 ()5
( ) None (no partition)
d. Adequacy of space: ( ) Adequate ( ) Inadequate
e. Lighting facility: ( ) Electricity ( ) Kerosene ( ) Others, specify:
f. Adequacy of Lighting: ( ) Adequate ( ) Inadequate
g. Ventilation: ( ) Adequate ( ) Inadequate
h. General Sanitary condition: ( ) Generally clean ( ) Dirty

B. Water Supply:

a. Ownership: ( ) Private ( ) Public

b. Water Source: NOTE: If deep well, proceed to letter “e”.

Cooking: ( ) Deep well ( ) Local Water District ( ) Commercial ( ) Others:_______
Drinking: ( ) Deep well ( ) Local Water District ( ) Commercial ( ) Others:_______
Bathing/CR/Flushing: ( ) Deep well ( ) Local Water District ( ) Commercial ( ) Others:_______

c. Potability (according to key informant): ( ) Yes ( ) No

d. Storage:
( ) None (direct from the faucet or pipe)
( ) Large covered container with faucet
( ) Large uncovered container with faucet
( ) Large covered container without faucet
( ) Large uncovered container without faucet
( ) Others, specify: ___________________________________________
e. Distance of source of water from the house: _______________________

C. Food Storage/ Cooking Facilities:

a. Food Storage: ( ) Covered ( ) Uncovered

b. Storage: ( ) Refrigerator ( ) Cabinet ( ) Basket ( ) Table
c. Cooking Facility: ( ) Electric stove ( ) Gas stove ( ) Firewood/charcoal ( ) Others:______
d. Sanitary condition ( base on observation): ( ) Generally clean ( ) Dirty

D. Waste Disposal:

a. Refuse and Garbage

1. Storage: ( ) Container ( ) None
2. Waste Segregation: ( ) Practiced ( ) Not Practiced
2.1 If practiced, method of disposal:
( ) Hog-feeding ( ) Open dumping ( ) Burial in pit
( ) Collected ( ) Composting ( ) Open burning
2.2 Reason for practicing:
( ) Environmentally friendly ( ) Barangay ordinance which is strictly monitored
( ) Use for business ( ) Others, specify:_________________________
2.3 If not practiced, method of disposal:
( ) Hog-feeding ( ) Open dumping ( ) Burial in pit
( ) Collected ( ) Composting ( ) Open burning
2.4 Reason for not practicing
( ) Not aware of effects ( ) No time to do it
( ) Long-time practice of family ( ) No barangay/municipality ordinance

b. Toilet Facilities:
1. Ownership: ( ) Owned ( ) Shared/Public ( ) None
2. Type:
( ) “Ballot system” ( ) Pail system ( ) Overhung latrine ( ) Antipolo type
( ) Open-pit privy ( ) Closed pit privy ( ) Bored- hole latrine
( ) Water- sealed ( ) Flush type ( ) None
3. Location from source of water: ( ) Less than 20 ft. ( ) 20 ft. beyond
4. Sanitary condition: ( ) Generally clean ( ) Dirty

c. Drainage System: ( ) Open drainage ( ) Blind drainage ( ) None

Condition: ( ) Flowing ( ) Stagnant

E. Presence of Animals that are Rabies carriers: ( ) Yes ( ) No

a. If yes, animals raised

Kind Number Kept Where With regular Without vaccination
Inside the Yard Free Outside vaccination

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 b. Practices measures done to control insects/vectors of diseases:
( ) Fumigation ( ) Insecticides ( ) setting traps ( ) Cleaning the yard ( ) None
c. Presence of breeding sites ( for observation):
( ) Yes ( ) No

F. Housing Congestion (for observation): ( ) Yes ( ) No

G. Presence of Industrial establishment/factory/ies (for observation): ( ) Yes ( ) No

III. HEALTH AND ILLNESS PATTERN

1. LIFESTYLE PRACTICES

A. Use of Safety Precaution

Practice Not Practiced
1. Use safety devices when necessary e. g. Helmet, safety belts

B. Is there a member of the family who is a cigarette smoker? ( ) Yes ( ) No ()

frequency/sticks or packs per day ________
Name Age Age started smoking Reason

C. Use of prohibited / dangerous drugs : ( ) Yes ( ) No ( ) Types

of Drugs : ______/Solvent_________
Name Age Age started using drugs Reason

D. Drinks alcoholic beverages

Name Age Age started drinking Frequency Reason
alcohol

2. NUTRITIONAL STATUS

A. Anthropometric Data (5 years below)

Age in Wt. Ht. in BMI Waist Hips Waist Hips Ratio
(Wt. in kg / Remarks Circumference Circumference (WC/HC) Remarks Mid Upper
Name mos. in kg. m (WC) in cm. (HC) in cm. Arm Circular
Remarks
Ht. in m2)

Legend for indices of Nutritional Status: Weight for Age (WFA)

B. Dietary History
24- Hour Food Recall
Date Time of the day Food taken
BREAKFAST
SNACK
LUNCH
SNACK
DINNER
MIDNIGHTSNACK

C. Food usually/most taken (General)

a. First choice: ( ) Meat only ( ) Fish ( ) Vegetable ( ) Mixed ( ) Others, specify:___
b. Number of servings: ()1 ( ) 2-3 ( ) 4-5 and above
c. Second choice: ( ) Meat ( ) Fish ( ) Vegetable ( ) Mixed ( ) Others, specify:___
d. Number of servings: ()1 ( ) 2-3 ( ) 4-5 and above

D. Reason for choices: ( ) Its healthy ( ) Own preference ( ) Affordable

( ) personal belief/practices ( ) Health condition

E. Reason for not choosing other options: ( ) Not healthy ( ) Own preference ( ) Not affordable
( ) personal belief/religious practices ( ) Health condition

F. From the above response, how frequent is the intake?( ) Everyday ( ) Twice a week ( ) Once a week
( ) Others, specify: ________________________

G. How is food prepared for mealtime? ( ) Prepared at home ( ) Bought outside

H. How often? ( ) Everyday ( ) Twice a week ( ) Once a week ( ) Others, specify:__________

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 I. If bought outside, is it from the: ( ) Restaurant/Fast food ( ) Carinderia
( ) Food cart e.g. Fried chicken sa kanto, provent, calamares

J. Reason for the above option: ( ) Convenient ( ) Cheaper ( ) Healthy

( ) Variety of choices ( ) Others, specify: ____________________________

K. Takes/eat canned/ preserved food e. g. Lucky me noodles, Maling, luncheon meat:

( ) Everyday ( ) Every other day ( ) Every week ( ) Sometimes ( ) Never

L. Takes/eat grilled foods: ( ) Everyday ( ) Every other day ( ) Every week ( ) Sometimes ( ) Never

M. Drinks carbonated beverages: ( ) Everyday ( ) Every other day ( ) Every week

( ) Occasionally ( ) Sometimes ( ) Never
3. BELIEFS AND PRACTICES

A. Person/nel mostly consulted in times of sickness/illness: ( ) Doctor ( ) Nurse ( ) Midwife ( ) Hilot

( ) Albularyo ( ) Faith Healer ( ) Elderly
B. Measures taken in times of sickness/illness: ( ) Consult a private health worker ( ) See a known community healer
( ) Consult a Rural Health Team ( ) Self- Medication ( ) None
C. Medication/ treatment taken in times of sickness/illness: ( ) Prescribed by Doctor ( ) Self-Medication/OTC drugs
( ) Herbals ( ) Others, specify: _________
D. Medical Check-Up whether in private or government institution: ( ) once a year ( ) twice a year ( ) more than a year
E. Dental Check-Up whether in private or government clinic: ( ) once a year ( ) twice a year ( ) more than a year

4. COMMUNITY HEALTH PROGRAMS

A. What are the Health Services available in the barangay health center? _________________________________
B. Immunization record
Incom Fully
Age Complete
DPT DPT DPT Hepa B Hepa B Hepa B OPV OPV OPV Meas plete Immun
Name in Gender BCG according
1 2 3 1 2 3 1 2 3 les accdg ized
mos to Age
to Age Child

C. Ante- natal Registration

Pre- Natal Check- Up Tetanus Vaccination
Name AOG With
Regular Not Regular Without With Without

D. Family Planning [only for: Women who are 12 yrs. (menarche age) to 40-45 yrs. (until menopause age); with partner(s); or plans
to get pregnant.]

1. Family Planning: ( ) Acceptor Reason:

( ) Good for health of family ( ) Personal belief
( ) Religious belief ( ) Influence by others
( ) Others, Specify:___________

( ) Non- Acceptor Reason:

( ) Bad for health of family ( ) Personal belief
( ) Religious belief ( ) Influence by others
( ) Others, Specify:___________

2. Modern Methods Used:

( ) A. Permanent method Like: ( ) Female sterilization / Bilateral Tubal Ligation ( ) Male sterilization / Vasectomy
( ) B. Temporary method:
( ) a. Supply Methods Like: ( ) Pills ( ) IUD ( ) Injectable ( ) Condoms

( ) b. Fertility Awareness-Based Method Like: ( ) Cervical Mucus/Billings Ovu.Method ( ) Basal Body Temperature
( ) Sympto-thermal Method ( ) Standard Days Method
( ) Lactational Amenorrhea Method
5. HEALTH INDICATORS

A. Morbidity
Intervention
Name Age Gender Cause With Without Admitted Not Admitted

B. Mortality (within the past 12 months)

Name Age Gender Cause of death

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 C. History/ Presence of Non Communicable Disease in the Family
Name Age Gender NCD

D. History / Presence of Communicable Disease in the Family

Name Age Gender CD

E. Blood Pressure Record for Ages 35 and above

Name Age Gender BP

F. Awareness of health services offered by the BHC/ RHU: ( ) Aware ( ) Unaware

IV. Health Resource: (Key Informant interview with the Barangay Officials)

1. Manpower Resources

A. Categories of health manpower available

B. Geographical distribution
C. Number of Physician, Nurse, midwife and other members of RHU team per population
D. Existing manpower development/ policies
E. Schedule of consultation at Barangay Health Center
RHU Physicians:____________________________
RHU Nurse:________________________________
BHC Midwife:_______________________________

2. Material Resources

A. Health and Budget Expenditures: ( ) Available ( ) Not-Available Amount per year: Php___________
B. Availability of supplies and equipment: ( ) Available100% ( ) Limited Supplies ( ) Not-Available

V. Political/ Leadership Patterns:

1. Recognized Leaders:
Formal/Elected: ( ) Captain ( ) Kagawad
Non-formal: ( ) Elderly ( ) BHW ( ) Influential person
( ) Religious leader ( ) Neighbor

2. Conditions/ events/ issues that cause social conflicts/ upheavals within the community
( ) Gossip ( ) Family conflict ( ) Drugs ( ) Riot ( ) Alcohol drinking
( ) Others, specify:_________________

3. Practices/ approaches which are effective in setting issues and concern within the community
( ) Settlement among involved parties ( ) Brgy. hearing ( ) Endorsed to local police
( ) Others, specify:_________________

VI. Any concerns/suggestions regarding the life style you have in the area in general.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
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