The Instrument (English Version)

COMMUNITY NEEDS ASSESSMENT QUESTIONNAIRE

A. IDENTIFICATION
1. Name of the Respondent :
2. Date of Interview :
3. Time of Interview :
4. Time Finished :
5. Name of Interviewer :

B. DEMOGRAPHIC DATA
1 2 3 4 5 6 7 8 9
N For children 0-1 years
Is birth
U old:
Relationship registered with
Gender Is/are the vaccine
M A. Father the local
Who are the members B. Mother Civil received right for the
Age Religion Birthday registrar?
B of the household? A. Male C. Children Status age of the child?
D. Others
E B. Female
A. Yes
R A. Yes
B. No B. No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
(4) Religion

A. Catholic
(3) Age (7) Civil Status
B. Protestant
C. Iglesia ni Kristo
A. 0-5 years old F. 30-35 years old K. 60-65 years old A. Single
D. Aglipay
B. 6-11 years old G. 36-41 years old L. 66 years old and B. Legally Married
E. Islam
C. 12-17 years old H. 42-47 years old above C. Widowed
F. Born-Again
D. 18-23 years old I. 48-53 years old D. Separated
G. Mormons
E. 24-29 years old J. 54-59 years old E. Live in
H. Jehovah’s witness
I. 7th day Adventist
J. Others
C. INCOME D. OFW E. EDUCATION
10 11 12 13 14 15 16 17 18
N What is the
U highest degree of
Do you have an Current
M education If given the
OFW in your educatio
achieved? chance to study
B family? n level? A. Elementary level
Work Status A. Yes, we Studying? again do we
E Income B. Elementary
Occupatio have How many A. graduate expect your
R n
per A. Permanent B. None years in A. Yes Preparatory C. High school level participation?
Month B. Temporary
B. No B. D. High school
C. Shifting abroad?
What country Elementary graduate
C. High E. College level A. Yes
does he/she
works?
school F. College graduate B. No
D. College G. Vocational
H. Out of school
I. Unable to study

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

F. HOUSEHOLD MEMBERS WITH DISABILITIES

19 20 21
N
U Does anyone in your family
M have a disability? What is the cause of
B
What kind of disability?
A. Yes, we have disability?
E B. No, we don't have
R
1
2
3
4
5
G. MIGRATION PATTERN
A. <3 years D. 12-15 years
22. How long was your family living in this village? B. 4-7 years E. 16-19 years
C. 8-11 years F. 20 years and above

23. What province did you came from?

24. Does every member of your family aged

18 or older are registered voters in your A. Yes B. No, why?
village?

H. HEALTH AND NUTRITION

25. Throughout the past twelve months,
A. Yes, we have B. None
is there anyone in your family member
died?

26. What is the cause of death? Number of family member died

_

27. During the past twelve months, has

any member of your household become
A. Yes B. None
sick/ill?

28. What was his/her last sickness?

29. What is usually done when sick?
A. Consulting a doctor
B. Consults an Albularyo (herb doctor)
C. Self-medication
D. Rest (Letting the disease passed by)
E. Uses herbal medicines (alternative)

A. Public hospitals
30. Where do you usually seek medical B. Private hospitals
C. Private clinics
help? D. Brgy. Health Center / Station
E. Non-medical/Non-trained/Hilot

A. Appearance of first symptoms

31. When do you seek medical help? B. When already ill
C. When the illness worsen

Questions for couples about Family Planning

32. Does the couple favors/agrees about
A. Yes B. No
family planning?
33. Does the couple use family planning? A. Yes B. No,
I. HOUSING
A. House/Lot owned
36. What is the status of your house and land B. House/Lot rented
residency? C. House/Lot rented free
D. Squatter

A. Barung-barong/Hut D. Two storey

37. What kind of housing?
B. Bungalow (One Storey) E. Apartment/condominium
C. Duplex
A. Strong materials (concrete, brick, stone, wood, galvanized iron, asbestos)
38. What are the materials used for the house?
B. Light materials (bamboo, sawali, cogon, nipa)
C. Salvaged/makeshift materials
39. Do you have an electricity supply? A. Yes, we have B. None, we do not have
A. Owned meter C. Submeter
40. What of kind of electricity supply? B. Jumper/Shared (nakikikabit) D. No meter
A. Faucet F. Rain water
B. Motor-powered artesian well G. Tanker truck
41. What is the source of your drinking water? C. Artesian well H. From a river, dam, etc.
D.Deep well (Water well) I. Bottled/Mineral water
E. Spring (Bukal)
A. Faucet F. Rain water
B. Motor-powered artesian well G. Tanker truck
42. What is the source of your household water? C. Artesian well H. From a river, dam, etc.
D.Deep well (Water well) I. Bottled/Mineral water
E. Spring (Bukal)
A. Inside the house/yard
43. How far is the source of your drinking water from B. Inside the yard <250 meters
your house? C. Outside the yard <250 meters
D. >250 meters

A. Flush toilet – used by a single family residence

44. What kind of toilet/lavatory that is used by your B. Flush toilet – used by two or more families with different residence
household? C. Pour flush toilet – used by a single family residence
D. Pour flush toilet – used by two or more families with different residence

A. Collected F. Open dumping

B. Burning
45. What is the system used in managing
C. Composting
garbage/trashes of households? D. Recycling
E. Waste segregation (Separation of biodegradable and non-biodegradable garbage)
A. Municipality garbage collectors
46. Who collects garbage/trashes? B. Private garbage collectors
C. Barangay garbage collectors
A. Everyday E. Every month
47. How frequent is the garbage collection of your B. Once (1) a week F. Twice (2) a month
community? C. Twice (2) a week G. Three (3) times a month
D. Three (3) times a week
J. CALAMITIES
48 49 50
For the last twelve months, does your Did you received any help from Where did you stayed temporarily?
the:
family encounter the following calamities?
A. Government (LGU, DSWD)
A. Yes, we do B. NGO (school, church, etc.) A. School D. House of relatives
C. Relatives
B. No, we didn't D. Acquaintances B. Church E. House of neighbour
E. No help received C. Covered court F. House of friends
1. Storm G. Have not yet experienced to evacuate
2. Flood
3. Drought
4. Earthquake
5. Landslide
6. Fire
51. Is your family prepared for any disaster? A. Yes, we are prepared B. No, were unprepared
52. Is issues about disasters are talked about in your family? A. Yes B. No
53. Do you have a disaster preparedness kit containing
water, food, first aid supplies, clothing and blankets,
matches, lighters, candles, flashlight, battery radio, whistle A. Yes, we have B. No, we do not have
and battery? (Available) (Unavailable)

54. Is there a presence of community exercises/training to

A. Present B. Absent
disaster that is conducted by your family member?
55. Do you know the evacuation/disaster plan of your
A. Yes, we are aware B. No, we are unaware
community?

K. LOCAL GOVERNMENT AND BARANGAY

A. Brgy. Captain C. Association President
56. To whom do you refer/consults first, when there are
B. Brgy. Counselor (Kagawad) D. Barangay Officials
problems or activities in your village?

A. Frequent trouble F. Plenty of drug users

B. Foul and dirty surroundings G. Crime is too often
C. Frequent flooding H. Quiet surroundings
57. How do you describe your environment?
D. Water Shortage I. Clean
E. Electricity Shortage J. Peaceful
K. Others

A. Perseverance
B. Help in organizing the community
58. What are your suggested solutions to problems in your
C. Depend on the government
surrounding environment?
D. Depend on NGO
E. Nothing we can do
L. PROGRAMS
59 60 61 62
During the past twelve months, what programs that What is the reason
was been implemented? for not attending?
Was the program's
A. Busy at work
contribution helpful?
What is the A. Attended B. Busy at home
sponsor of the B. Not (taking care of
A. Yes
A. Yes program? attended children)
Kind of programs B. No A. C. Unaware about
B. No
Government C. Not Utilized
the program
B. Private D. Not interested
1. Family Planning Program

2. NFA rice program (Programa ng

NFA na nagbebenta ng mas murang
bigas)

3. Mother and Child Care Program

4. Food for school Program

(Programa na nagbibigay ng pagkain
sa mga estudyante sa paaralan)
5. Under five Nutrition Program

6. Food for work (Programa na

nagbibigay ng pagkain sa mga
nagtatrabaho)

7. Expanded Program on
Immunization

8. Health Insurance (Maxicare,

Medicare, Philhealth, Intellicare and
the like)
9. Control of Acute Diarrheal
Diseases

10. Medical Mission

11. Control of Acute Respiratory

Infection

12. Education/ Scholarship program

(Programa na nagbibigay tulong sa
pag-papaaral)

13. Operasyon Timbang Program

14. Livelihood training program

(Programa na nagbibigay ng
pagsasanay sa anumang gawaing
pangkabuhayan)
15. National Tuberculosis Program

16. Program for monetary lending

(credit)

17. Primary Health Care and First

Aid Program