Activity 5

Community Needs Assessment

Survey Instrument
(Community Based Problems and Needs)

I. Personal Information:

Respondent: _______________________________________________________________
Role in the Family: _________________________________________________________
Civil Status: ( ) Single ( ) Married ( ) Widowed/ Separated
Age: _______
Date of Birth: ________
Address: ___________________________________________________________________
Distance of house to the town proper in Km.: ________________________________
Work: ______________________________________________________________________
Salary/ Wages: _____________________________________________________________

II. Members of the household:

Name Age Sex Civil Education Occupation

Status

Type of House and materials made of:

Concrete ( ) Wood ( ) Combination of concrete and light materials ( )

Others: _________________________________________

Small House made of light materials

Nipa/cogon ( ) bamboo/ wood ( )

III. Questionnaire:

Direction: Please check the following question.

1. Do you know how to read and write?

Yes ( ) No ( )

2. Can you identify problems and needs of your community?

A. Literacy
_________ many cannot read and write
_________ shortage of teachers and books
_________ there is no reading centre in the area
_________ the school are far from the area
_________ we need people who can teach us how to read and write

B. Health and Sanitation

__________The health center is far from our area.
__________ we have no decent toilet
__________ Garbage are scattered everywhere
__________ Children get sick oftentimes and they are weak
__________ Source of potable water is scare

C. Liveliehood
_________ many resident do not have work
_________ There is no space for planting vegetables and crops.
_________ Resident find difficult in engaging income generating
project.

D. Drugs
________ rampant problem in the community
________ idleness of the youth
________ peer pressure/ pakikisama
________ family problem
________ Environmental influence

What do you think are the priority of your barangay?

_________ Literacy
_________ Health and Sanitation
_________ Livelihood
_________ Drugs
_________ How to manage a community
_________ Others