COMMUNITY PROFILE FORM COMMUNITY PROFILE FORM

Put a check on the blank of your response or write the Put a check on the blank of your response or write the
corresponding information needed. corresponding information needed.

NAME: __________________________ DATE: _________ NAME: __________________________ DATE: _________

COMPLETE ADDRESS: COMPLETE ADDRESS:

_______________________________________________ _______________________________________________

RELIGION: _______________ RELIGION: _______________

SEX: ____ MALE ____ FEMALE SEX: ____ MALE ____ FEMALE

AGE: ____ 15-16 ____17-18 ____19 AND ABOVE AGE: ____ 15-16 ____17-18 ____19 AND ABOVE

TYPE OF FAMILY: TYPE OF FAMILY:

____ NUCLEAR ____ EXTENDED ____ SINGLE PARENT ____ NUCLEAR ____ EXTENDED ____ SINGLE PARENT

NUMBER OF SIBLINGS: ____ NUMBER OF SIBLINGS: ____

FAMILY INCOME PER MONTH: ____PHP5000 ____PHP8000 FAMILY INCOME PER MONTH: ____PHP5000 ____PHP8000

____PHP10000 ____PHP15000 ____ PHP16000 AND ____PHP10000 ____PHP15000 ____ PHP16000 AND
ABOVE ABOVE

NAME SOME BUSINESS ESTABLISHMENTS IN YOUR NAME SOME BUSINESS ESTABLISHMENTS IN YOUR
COMMUNITY: ___________________________________ COMMUNITY: ___________________________________

DO YOU HAVE SCHOOL IN YOUR COMMUNITY? DO YOU HAVE SCHOOL IN YOUR COMMUNITY?

____YES____ NO ____YES____ NO

IF YES, ____ DAY CARE CENTERS ____ ELEMENTARY IF YES, ____ DAY CARE CENTERS ____ ELEMENTARY

____ HIGH SCHOOL ____ COLLEGE ____ HIGH SCHOOL ____ COLLEGE

ARE HEALTH SERVICES AVAILABLE IN YOUR COMMUNITY? ARE HEALTH SERVICES AVAILABLE IN YOUR COMMUNITY?

____ YES ____ NO ____ YES ____ NO

IF YES, ____ HEALTH CENTER ____ CLINIC IF YES, ____ HEALTH CENTER ____ CLINIC

____ PUBLIC HOSPITAL ____ PRIVATE HOSPITAL ____ PUBLIC HOSPITAL ____ PRIVATE HOSPITAL