HOUSEHOLDS THAT PRACTICE WASTE SEGREGATION

BARANGAY: ________________________

Total Number of Households: _____________ Date of Survey:________________

Purok Household Head of the Family Practice REMARKS

No. Segregation *COMPLIANT OR
NON COMPLIANT
YES NO

Inspected by:

____________________________ _______________________________________
Barangay Health Worker Barangay Committee on Environment, Chairman

Noted by:

________________________________________
Barangay Captain

* Please, provide Photo Documentation*