CAF FORM 6 Republic of the Philippines

NATIONAL STATISTICS OFFICE 6A

AUTHORITY: Manila
Section 2(c) of Commonwealth Act (CA) No. 591
authorizes the National Statistics Office to prepare for
and undertake all censuses of population, agriculture,
industry and commerce.
2012 CENSUS OF AGRICULTURE 6
AND FISHERIES
CONFIDENTIALITY:
Section 4 of CA No. 591 provides that all information
furnished on this form is held STRICTLY
CONFIDENTIAL. BARANGAY QUESTIONNAIRE NSCB Approval No. NSO-1218-06
Expires on October 9, 2013
(TO BE ACCOMPLISHED BY THE TEAM SUPERVISOR)
CERTIFICATION GEOGRAPHIC IDENTIFICATION
I hereby certify that the data set forth herein were
personally obtained/ reviewed by me and in PROVINCE _____________________________________________
accordance with the instructions given by the
National Statistics Office.
CITY/MUNICIPALITY _____________________________________________

_________________________________
TEAM SUPERVISOR TS CODE
(SIGNATURE OVER PRINTED NAME)
BARANGAY _____________________________________________

______________________________________________
DATE ACCOMPLISHED INTERVIEW RECORD

______________________________________________ NAME OF RESPONDENT ______________________ _______________________

DSO/SCO LAST NAME FIRST NAME
(SIGNATURE OVER PRNTED NAME)
DESIGNATION/POSITION
______________________________________________ IN THE BARANGAY __________________________________________________
DATE REVIEWED
ADDRESS OF THE
______________________________________________ BARANGAY HALL __________________________________________________
CO/RO/PO SUPERVISOR – DESIGNATION STREET AND/OR SITIO/PUROK NAME

______________________________________________
DATE REVIEWED
DATE OF VISIT TIME BEGAN TIME ENDED
MONTH : DAY HOUR : MINUTE HOUR : MINUTE

INSTRUCTION: ASK ALL QUESTIONS. WRITE X IN THE BOX FOR CODE “1” (YES) OR CODE “2” (NO), ASK FOR THE NUMBER
OF FACILITIES, INPUT DEALERS, AND SERVICE PROVIDERS THAT ARE PRESENT/AVAILABLE IN THE BARANGAY.
PART I – PRESENCE/AVAILABILITY OF AGRICULTURAL, AQUACULTURAL, AND FISHERY FACILITIES, INPUT DEALERS,
AND SERVICE PROVIDERS IN THE BARANGAY
A. FACILITY
In your barangay, is there a/an . . . ?
1 Q1 rice or corn mill? 1 Yes, how many? ___________ 2 No

Q2 mobile rice or corn mill? 1 Yes, how many? ___________ 2 No

2 Q1 feed mill? 1 Yes, how many? ___________ 2 No
3 Q1 slaughterhouse/dressing plant? 1 Yes, how many? ___________ 2 No
4 Q1 agricultural processing facility/machinery/equipment? 1 Yes, how many? ___________ 2 No

Q2 mobile agricultural processing facility/machinery/equipment? 1 Yes, how many? ___________ 2 No

5 Q1 fish landing center? 1 Yes, how many? ___________ 2 No
6 Q1 periodic or permanent agricultural produce market (“bagsakan/bulungan”)? 1 Yes, how many? ___________ 2 No
7 Q1 hatchery (for poultry and aquafarm species)? 1 Yes, how many? ___________ 2 No
8 Q1 breeding/multiplier farm (for livestock and poultry)? 1 Yes, how many? ___________ 2 No
9 Q1 nursery/greenhouse/screenhouse/nethouse? 1 Yes, how many? ___________ 2 No
B. INPUT DEALER
In your barangay, is there a . . . ?
1 Q1 fertilizer dealer? 1 Yes, how many? ___________ 2 No

Q2 mobile fertilizer dealer? 1 Yes, how many? ___________ 2 No

2 Q1 pesticide dealer? 1 Yes, how many? ___________ 2 No

Q2 mobile pesticide dealer? 1 Yes, how many? ___________ 2 No

3 Q1 seeds dealer? 1 Yes, how many? ___________ 2 No

Q2 mobile seeds dealer? 1 Yes, how many? ___________ 2 No

4 Q1 feeds dealer? 1 Yes, how many? ___________ 2 No

Q2 mobile feeds dealer? 1 Yes, how many? ___________ 2 No

5 Q1 veterinary medicine dealer? 1 Yes, how many? ___________ 2 No

Q2 mobile veterinary medicine dealer? 1 Yes, how many? ___________ 2 No

 PART I – PRESENCE/AVAILABILITY OF AGRICULTURAL, AQUACULTUAL, AND FISHERY FACILITIES, INPUT DEALERS,
6B AND SERVICE PROVIDERS IN THE BARANGAY
C. SERVICE PROVIDER
In your barangay, is there a/an . . . ?
1 Q1 veterinary/paraveterinary clinic/service? 1 Yes, how many? ___________ 2 No

Q2 mobile veterinary/paraveterinary clinic/service ? 1 Yes, how many? ___________ 2 No

2 Q1 rental service of farm machinery/equipment? 1 Yes, how many? ___________ 2 No
3 Q1 financial credit institution:

i. commercial bank (including rural bank)? 1 Yes, how many? ___________ 2 No

ii. government bank? 1 Yes, how many? ___________ 2 No

iii. cooperative bank? 1 Yes, how many? ___________ 2 No
iv. microfinance institution? 1 Yes, how many? ___________ 2 No
v. individual money lender? 1 Yes, how many? ___________ 2 No
vi. self-help group? 1 Yes, how many? ___________ 2 No
vii. other sources? SPECIFY __________________________________ 1 Yes, how many? ___________ 2 No
4 Q1 training and/or extension services to farmers and fisherfolks offered by:
i. cooperative? 1 Yes, how many? ___________ 2 No
ii. farmers’/fishermen’s organization? 1 Yes, how many? ___________ 2 No
iii. local government unit? 1 Yes 2 No
iv. nongovernment organization? 1 Yes, how many? ___________ 2 No
v. others? SPECIFY _______________________________________ 1 Yes, how many? ___________ 2 No

PART II – DESTRUCTIVE NATURAL CALAMITY IN THE PAST FIVE YEARS

Q1 During the past five years, that is, from January 2008 to December 2012, did your barangay experience destructive natural calamities such as a/an . . .

1 typhoon? 1 Yes, how many times? ______ 2 No

2 flood? 1 Yes, how many times? ______ 2 No

3 earthquake? 1 Yes, how many times? ______ 2 No

4 volcanic eruption? 1 Yes, how many times? ______ 2 No

5 tsunami? 1 Yes, how many times? ______ 2 No

6 landslide/mudslide? 1 Yes, how many times? ______ 2 No

7 infestation/animal disease? 1 Yes, how many times? ______ 2 No

8 drought? 1 Yes, how many times? ______ 2 No

9 others, SPECIFY __________________________________________ 1 Yes, how many times? ______ 2 No

PART III – DOMINANT TERRAIN OF THE BARANGAY

Q1 What is the dominant terrain of your barangay ?

1 coastal 3 plain

2 mountainous/hilly 4 others, SPECIFY ________________

REMARKS: