A.

IDENTIFICATION COMPLETE ADDRESS

Region: Province:
Municipality: Village:
Household Number: Household ID Number:
Region: Contact Number:

Date: Times Started:

Interview / Started: Skills:
B. DWELLING

1. In what type of building does the household reside?

__Single __Multi unit residential
__Duplex __Commercial/Industrial /agricultural bldg. /house
__Others (boat, cave, etc) ___________________
2. How many bedrooms does the housing unit have? ___
3. What type of construction materials are the roofs made of?
__Strong materials (concrete, brick, stone, wood, galvanized iron)
__Light materials (bamboo, sawali, cogon, nipa) __ Mixed but predominantly light materials
__Salvage/makeshift materials __Mixed but predominantly strong materials
__ Mixed but predominantly light materials __Not applicable
4. What type of construction materials are the walls made of?
__Strong materials (concrete, brick, stone, wood, galvanized iron) __Light materials (bamboo, sawali, cogon, nipa)
__Salvage/makeshift materials __Mixed but predominantly strong materials
__ Mixed but predominantly salvaged materials __ Mixed but predominantly light materials
__Not applicable
C. HOUSEHOLD CHARACTERISTICS
__How many members of the household are OFWs? __How many families are there in the household?
__Are there of the household who are pregnant? __ Are there of the household who are solo parents?
__ Are there of the household who are PWD?

NAME OF HOUSEHOLD MEMBER: __________________________________________

F. KOMUNIDAD
__ is he/she a registered voter? __if yes, did he/she vote last election?

G. ECONOMIC ACTIVITY
__ 1. Did he/she do any work for least one hour during the past week? Y/N
__2. If No, although he did not work, he has a job or business during the past week? Y/N
__2.1. If NO, did he look for work, or try to establish business during the past week? Y/N
__2.2. If NO, why he did not look for work?
__Tired/believes no is available __Household family duties
__Awaiting results for job application __Temporary illness/disability
__Schooling __Others (specify)______________________
__2.3. When was the last time he looked for work? (No of week/s moth/s)
__2.4. Had opportunity for work existed during the past week, would he have been available Y/N
__2.5. Is he willing to take up work during the past week or, within next two weeks? Y/N
__2.6. In the past 12 months, how much is the salary/wages (in cash) received by him?
__2.7. In the past 12 months, how much is the total salary/wages (in kind) received by him?
3. If YES, how many job/business does he have?________________________________________
4. What is his primary job, occupation, or business during the past week?__________________
5. Occupation code_________________________________________________________________
6. In what kind of industry did he work during the past week? ____________________________
7. Sector code_____________________________________________________________________
8. What is his nature of employment?__________________________________________________
__Permanent __Short term, seasonal, casual __Worked on different Jobs on day to day or week to week?
__Worked on different Jobs on day to day or week to week?
__8.1 What is his normal working hours per day during the past week?
__8.2 What is the total number of hours worked during the Past week?
__8.3 Did he want mire hours of work during the past week?
__8.4 Did he look for additional work during the past week?
9. What is his class of worker?
__Working for private __Working for private business/establishment/farm
__Working for government/government corp. __Self-employed without any paid employee
__Employer in own family-operated farm or bsiness __Working with Pay on own family-operated farm or business
__Working without on own family-operated farm or business
10. Is he a member of SSS/GSIS?
__SSS only __GSIS only __Both __Neither
11. Is he a victim of crime in the past 12months?
11.1 If yes, what crime/s was/were he became a victim of?
__Theft __Rape __Physical injury __Carnapping __Cattle rustling
__Other crime (specify)_____________________________
11.2 Where did the happen?
__Within the brgy __Outside the brgy biy within the municipality
__Outside the municipality but within the province __ Outside the province
11.3 Where was he/she residing three years ago?
__same address __other address (specify)__________________________
K. WATER AND SANITATION
1. What is your household
__Own faucet, community water system
__Shared faucet, community water system __ Own use tubed/piped Deep well
__ Tubed/piped shallow well __Dug well
__Protected spring __Unprotected spring
__Lake, river, rain, and others __Peddler
__bottled water __Others
2. What type of toilet facility does the household use?
__Water sealed, sewer septic tank used exclusively by household
__Water sealed, sewer septic tank shared with other households
__Water sealed, other depository, used exclusively by households
__Water sealed, other depository, shared with other households
__closed pit
__open pit
__Other, (pail system and others)
__None
L. HOUSING

1. What is the tenure status of the housing unit and lot occupied by your household?
__Owner, owner like possession of the house and lot
__Rent house/room including lot
__Own house, rent lot
__Own house, rent free lot with consent of owner
__Own house, rent free lot without consent of owner
__Rent free house and lot with consent of owner
__Rent free house and lot without consent of owner
__Living with public space without rent
__Other tenure status
2. In your own estimates, how much is the imputed rent per month for the house and/or lot? __________
3. Is there electricity on the dwelling place?
If YES, what is the source of electricity in the dwelling place?
__Electric company __Generator
__Solar __Battery
__Others
4. Assets / Amenities
How radio does the household own? How many TV
How many vhs, dvd player? How many stereo / component does the household own?
 How many karaoke Refrigerator
How many ref acquired in less than 3 years ago? Electric fan
Electric iron Lpg.gas stove/range
Washing machine Oven
Computer Internet connection
Cellphone No of cellphone acquired in less than 3 yrs
Telephone Aircon
Sewing machine No of sewing machine in less than 3 years
Vehicles Tricycle or motorcycle
How many agricultural land does the hh own? How many residential land does the hh own?
How many commercial land does the hh own? How many sofa/sala
Dining set How many other type of amenity does the hh own?
Type of assest How many of the asset was acquired in less than 3 years?

5. Insurance (YES OR NO)

__Do you have an insurance __Do you have insurance for vehicle? __Do you have insurance for appliances?

M. WASTE MANAGEMENT
1. What is the system of garbage disposal by the household? Y/N
__Garbage collection __Burning
__Composting __Recycling
__Waste segregation __Pit and cover
__Pit w/o cover __Throwing of garbage in river, vacant lot, etc.
__others, specify_______________

2. Garbage collection details

2.1 Who collects the garbage? 2.2 How often is the garbage collected
__Municipal garbage collector __Daily
__Barangay garbage collector __Thrice a week
__Private __Twice a week
__Others __Once
__Others
N. SOURCE OF INCOME
1. ENTREPRENEURAL ACTIVIES
__1.1 Crop farming and gardening such as growing palay,corn, roots, and tubers, vegetables, fruits, nuts, ornamental plants, etc. Y/N
If yes, income from crop farming and gardening in cash______ in kind ________

_1.2 Livestock and poultry raising such as raising of carabaos, cattle, hogs, horses, chicken, ducks, and the production of fresh
milk,eggs, etc. Y/N
If yes, income from raising in cash _______in kind___________?

__1.3 Fishing activities such as capture fish, gathering of fry, shells, seaweeds, etc. culturing fish, oyster, mussels, etc. Y/N
If yes, income from fishing in cash______in kind ___________?

__1.4 Forestry and hunting activities such as tree planting (falcate, gmelina, rubber, trees, etc) firewood gathering, small scale logging,
charcoal making, gathering of forestry product (cogon, nipa, rattan, bamboo, resin, gum, etc.) or hunting of wild animals.
Y/N
If yes, income from forestry and hunting cash________in kind__________?

__1.5 Wholesale and retail trade including market vending, sidewalk vending and pending,etc.
If yes, income from wholesale/retail in cash ________ in kind_____________?

__1.6 Manufacturing activities such as mat weaving, tailoring, dressmaking, bagoong making, fish drying, etrc. Y/N
If yes, income from manufacturing in cash ___________ in kind ________________?

__1.7 Community, social and personal services such as medical and dental practice, practice and trade, operation of school, restaurants
and hotels, etc. Y/N
__ If yes, income from community, social and personal services in cash _______in kind ___________?
 __1.8 Transportation, storage and communication service such as operation jeepneys or taxis. Storage and warehousing activities,
messengerial services, etc. Y/N
__ If yes, income from transportation, storage and communication services in cash ________in kind _______?

__1.9 Mining and quarrying activities such as mineral extraction like salt making, gold mining, gravel, sand and stone quarrying etc.
Y/N
__ If yes, income from mining and quarrying activities services in cash ______ in kind _____________?

__1.10 Construction like repair house, building, or any structure activities not elsewhere classified, including electricity gas and water,
financing, insurance, real estate and business services NEC. Y/N
__If yes, income from construction services in cash ____________ in kind__________?

2. SALARIES AND WAGES

__Cash __Kind
3. OTHER SOURCES OF INCOME
__Net share of crops __Cash __Kind
4. REMITANCES FROM OFW
__Cash __Kind
5. OTHER CASH RECEIPTS, GIFT, SUPPORT, RELIEF AND OTHER INCOME FROM ABROAD INCLUDING PENSION, RETIEMENT,
WORKMEN’S COMPENSATION, DIVIDENS FROM INVESTMENTS, ETC.
__Cash __Kind
6. CASH receipts, support, assistance, relief and pther income from domestic sources, including assistance from the government and private sources
__Cash __Kind
7. Rentals received form non-agricultural lands, buildings, spaces, and other properties
__Cash __Kind
8. Interest from bank deposits, interest from loans extended to the other families
__Cash __Kind
9. Pension and retirement, workmen’s compensation and social security benenfits
__Cash __Kind
10. Dividends from investments
__Cash __Kind
11. Other sources of income not elsewhere classified
__Cash __Kind
O. AGRICULTURE
__How many agriculture land does the household operate
__During the past 112 months, how many types of temporary and permanent cops did your hh harvest?
__Do you or any member of the hh use any og the ff. agri equipment/ facilities? Y/N if Yes, No of facility or equipment

__Beast of burden __Turtle/mud boat

__Plow __Planter/trans planter/dryer
__Harrow __Mechanical dryer
__Mower __Multipurpose drying pavement
__Thresher/ corn Sheller __Rice/corn/feed mill
__Insecticide pesticide sprayer __Harvester
__Farm tractor __Warehouse granary
__Hand tractor __Irrigation pump
__Farmshed
__Others (specify) other equipment ____________________

R. CLIMATE CHANGE
1. How many years has the household been living in its current dwelling unit?
__3 years and above __not more than 3 years (PROCEED TO CALAMITY)
IF 3 YEARS ABOVE:
1. AGRICULTURE
__1.1.1 How many years has the household been engaged in crop farming?
__1.1.2 Compare to 3 years ago, did your harvest
__Decreased
what is the primary reason for the decrease in harvest?
__increase in cost of farm inputs such as seeds, pesticides, etc. __affected by drought
__affected by typhoon __affected by pests
__decrease in supply of water from irrigation __change in primary occupation of member
 __others, specify___________________ __increased
__No change
__1.1.3 In the past 3 years, did you change the variety of the same crop in the last planting season?
if YES, why did you change crop?
__The former crop is more expensive __More resistant to pests and diseases
__The present crop crop does not require much water __The present crop enables the member to earn more profit
__Availability of crops __Others
__1.1.4 During the past 3 years, did you change maor crops in the last planting season
if YES, why did you change primary crops
__The former crop is more expensive __More resistant to pests and diseases
__The present crop does notrequire much water __The present crop enables the member to earn more profit
__Availability of crops __Others
__1.1.5. Do you have crop insurance?
if YES, who is the crop insurance provider?
__Philippine Crop Insurance corporation __Private Insurance Company
__Bank __Other (specify)
__1.1.6. Do you have agricultural equipment/facilities insurance/
__Philippine Crop Insurance provider? __Private Insurance Company
__Bank __Other (specify)
1.2. TEMPERATURE AND ELECTRICITY
__1.2.1. Compare to 3 years ago, is the temperature hotter now in your area? Y/N
__1.2.2. Compared to 3 years ago, are brownouts more frequent now in your ares?
1.3 SEA LEVEL
__1.3.1 Compared to 3 years ago, did the sea level __ in your area?
__Decreased __Increased __Remained the same __Don’t know __Not applicable
1.4 WATER SUPPLY
__1.4.1. Compared to 3years ago, did the water supply ____in your area?
__decreased
what is the primary reason for the decrease in water supply?
__drought __broken faucet __lower water level in the dam
__less frequent delivery of consumers __Increased __no change __Others (specify)
1.5. FLOOD
__1.5.1 Compared to 3years ago, do floods occur more often your area now? Y/N
___Three years ago, how long does it usually take for the flood to subside? (No. of hours)
___During the past 12 months, how long does it usually take for the flood to subside? (No. of hours)
2. EVACUATIN
__During the pans three years ago, did you move-out/leave your previous dwelling unit? Y/N
If yes, what is the primary reason of moving out/evacuation form the previous dwelling unit
__Kalamidad __Armed conflict __Infrastructure devt project __Others (specify)
__During the past three years, did you temporarily evacuate your house because of any calamity? Y/N
if yes, where did you stay when you temporarily evacuated
__School __Church __covered court/gym __Relative’s house
__Neighbor or friend’s house __Other (specify)
3.CALAMITY
CALAMITY YES FREQUENC RECEAIVED AID? PROVIDER
OR Y YES OR NO (National, Province, Municipality, Barangay,
NO Distrct/Congress, NGO, Don’t know, N/A
TYPHOON
FLOOD
DROUGHT
EARTHQUAKE
VOLCANIC ERUPTION
LANDSLIDE
TSUNAMI
FIRE
FOREST FIRE
ARMED CONFLICT
OTHERS (SPECIFY)
4. DISASTER PREPAREDNESS
__Do you have a disaster preparedness kit?
if yes, do you have the if, in your disaster preparedness kit? Y/N and if yes
how many supply will last?
__Water __Medical kit __ Lighter __Food __Whistle __ Emergency light
__Matches __Clothes __Other (specify) __Flashligth __Battery __Candles
__Important Documents
S. HUNGER
__In the last three months, did it happen even once thet your household experiences hunger and did not have anything to eat?
if yes,
__First month (name of the month) __Number of days
__Second month __Number of days
__Number of days of shortage in the second month __Third month
__Number of days shortage in the third month
T. PREVIOUS HOUSEHOLD MEMBERS
__Was there any household member who died in the past 12 months?
__if yes, how many dealth?
U. PROGRAMS (CONTINUATION)
__How many other programs did your household receive?
Type of program
__HMO/other health insurance __Medical/health assistance
__Supplemental feeding program __Schoolarship/education program
__Livelihood/skill training program __Credit program
__Housing program __Other program (specify)
Name of Program____________________________________
How many members covered by the program
What is/are the name/s of the beneficiary/ies of the program
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Who implemented the program?
__Nationa __Provinc __Municipality __Barangay __Congress/District __NGO’s
__Don’t know __Others
V. PROBLEMS AND NEEDS IDENTIFIED AS RESIDENT OF THE COMMUNITY
Check the problems/concerns which you think are pressing to the community.
__Children working in the farms/anykind of work. (state the nature of work).
__Children engaged in prohibited drugs/smoking/dringking/gamling/ other vices.
__Fathers engaged in drinking and gambling.
__Fathers with no permanent work.
__Children/youth addicted to online games.
__Member of family inflicting violence to other family members.
__Unproductive mothers due to idleness.
__Mothers engaged in gambling such card playing and others.
__Unsanitary/risky environment (state the nature of risk).
__Unsafe water to drink.
__Malnutrition problem among pre-schoolers.
__Presence of the children below 5 years old not attending ECCD.
__Children 0-6 years old not registered with the Local Civil Registrar.
__Member/s of the family who is/are differently abled person/s with special need/s.
__Children/Women /Men engage in prostitution.
__Children age 5 years old below who suffer severe or under malnourishments.
__Children age 18 years old below who have hazardous work.
__Single parents staying with the family.
__Members of the family, who were vicim of crime against humanity, such as abuse; rape and others physical violence/abuse.
__Members of the family who were victims against property, like robbery, stealing, and other such victims.
__Members of the family, who were victims/ once affected of natural calamity, such as typhoon.
__Members of the family, who were victims of armed conflict.
__________________________________________________Other problems (Please specify)