COMMUNITY NEEDS ASSESSMENT SURVEY QUESTIONNAIRE

NAME (Optional): ____________________________________________________

SEX: ( ) Male ( ) Female

AGE:
( ) 0 to 11 mos ( ) 1 to 12 Yrs. Old ( ) 13 to 18 Yrs. Old
( ) 19 to 30 Yrs. old ( ) 31 to 59 Yrs. Old ( ) 60 Yrs. Old and Above

CIVIL STATUS:
( ) Single ( ) Married ( ) Widowed ( ) Separated
( ) Cohabiting Relationship

NUMBER OF CHILDREN:
( ) 1 to 2 ( ) 3 to 4 ( ) More than 5

EDUCATIONAL ATTAINMENT:
( ) Elementary Undergraduate ( ) Elementary Graduate ( ) High School Undergraduate
( ) High School Graduate ( ) College Undergraduate ( ) College Graduate
( ) Vocational ( ) None

RELIGION:
( ) Roman Catholic ( ) Seventh Day Adventist ( ) Baptist
( ) Born Again ( ) Church of Jesus Christ and Latter day Saints
Others:_________________

EMPLOYMENT:
( ) Employed ( ) Unemployed

SOURCE OF INCOME:
( ) Agricultural ( ) Day Labor ( ) Business
( ) None Others: ________________

HOUSEHOLD INCOME PER MONTH:

( ) Below 5,000.00 ( ) 5,001.00 to 10,000.00
( )10,001.00 to 15,000.00 ( ) Above 15,000.00

HOUSING CONDITIONS:
( ) Government Owned ( ) Private Owned

MADE OF:
( ) Wood ( ) Cement ( ) Bamboo Others:______________

WATER FACILITIES:
( ) Government Water District ( ) Own with Pump ( ) Deep Well
( ) Others ____________

ELECTRICITY FACILITIES:
( ) With Electricity ( ) Without Electricity

SANITATION:
( ) With Toilet ( ) Without Toilet

MEANS OF TRANSPORTATION:
( ) Jeepney ( ) Motorcycle ( ) Bicycle Others: ________________

HEALTH CONDITIONS: ________________________________

SOCIAL SECURITY: ______________________

APPLIANCES:
Television
Radio
Refrigerator
Electric Fan
Washing Machine
Dryer
Air-conditioner
DVD Player
Wifi Modem
Rice Cooker
Computer Set/ Laptop
Printer
Stove Burner

Others: _______________________

MONTHLY HOUSEHOLD EXPENSES:

Electricity
Water
Transportation
Medical Needs
Education
Food Supply
Rent/Housing

Others: ____________________________