FAMILY SERVICE AND PROGRESS RECORD

HEAD OF THE FAMILY: ____________________________________________________________________ FAMILY NO.: _____________

ADDRESS: _____________________________________________________________________________________________________________

I. ASSESSMENT OF THE FAMILY, HOME AND ENVIRONMENTAL CONDITIONS:

A. MEMBER OF THE HOUSEHOLD

FAMILY RELATION SEX MARITAL BIRTHDATE HIGHEST OCCUPATION REMARKS/

MEMBER TO THE STATUS EDUCATIONA DATE
HEAD L ENTERED
ATTAINMENT
NO. NAME MONTH DAY YEAR TYPE OF PLACE OF
WORK WORK

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FAMILY RESIDENCE NOT SEGREGATED
EXCRETE DISPOSAL
HOME OWNERSHIP o SERVICE TYPE LATRINES
o OWNED o SERVICE TYPE LATRINES
o RENTED
o RENT- FREE PEST AND VERMIN CONTROL
o BIOLOGICAL
ADEQUACY OF SIZE o CHEMICAL
o ADEQUATE o ELECTRONIC
o INADEQUATE

STRUCTURAL SAFETY FAMILY NEIGHBORHOOD

o WOOD
o SEMI- CONCRETE SAFETY AND SECURITY
o CONCRETE o POLICE
o PRIVATE
WATER SANITATION
o PRIVATE TRAFFIC
o PUBLIC o LIGHT
o MODERTAE
FOOD STORAGE AND PREPARATION o HEAVY
o REFRIGERTION
o NON- REFRIGERATION LIGHTING
o ELECTRICITY
SEWAGE o KEROSINE
o OPEN
o CLOSE POPULATION DENSITY
o CROWDED
GARBAGE DISPOSAL o NOT CROWDED
o SEGREGATED

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