SALINAS WESTPOINT COLLEGE INC.

2nd Floor 248 SS Abutin Bldg., General Trias Drive, Tejeros Convention Rosario, Cavite, 4106
Tel. No. (046) 477-2675 E-mail address: salinaswestpointcollegeinc@gmail.com

SURVEY FORM

Group 1 Civic Welfare Training Service

Subject: Assessing proper waste management in CCAT street of Barangay Tejeros
Convention, Rosario, Cavite.
A. Demographic Profile
1. Who is the head of the family?
2. How many members are there in your family?
3. What is your highest degree or level of school you have completed? ( optional)
4. What is your marital status?
5. What is your current employment status?
6. How much is the total income of the family?
B. Health

1. Is there anyone in the family who has a health problem? Who and what type of
health problem?
2. Check the following health problems that exist in the family history.
Heart Disease ____
Kidney Failure ____
Ulcer ____
Hypertension ____
Diabetes ____
Others, Specify; ________________
3. Is there anyone in the family who drinks alcohol?
4. Is there anyone in the family who smokes?
5. What are the common recreational activities the family enjoys?
6. Did you / your family maintain any kind of exercise?
7. From the health issues, you identified above, please indicate the top three issues
you are most concerned with?
1)_______________________________________________________________
 SALINAS WESTPOINT COLLEGE INC.
2nd Floor 248 SS Abutin Bldg., General Trias Drive, Tejeros Convention Rosario, Cavite, 4106
Tel. No. (046) 477-2675 E-mail address: salinaswestpointcollegeinc@gmail.com

2)_______________________________________________________________
3)_______________________________________________________________
8. In the following list, what behaviors have you or a family member have
experienced in
the last year (check all that apply)?
a)Alcohol abuse
b) Being overweight
c) Dropping out of high school
d) Lack of exercise (less than two
e)times each week)
f) Not getting “shots” to prevent disease
g)Not using birth control
h) Not using seat belts/child safety seats
i) Poor eating habits
j)Tobacco use
k)Unsafe sex
Others please specify: ________________________________
9. Was there was a time in the past year that you or anyone in your family needed
medical care but could not get it, what were the reasons you did not get care (check
all that apply)?
a) Does not apply
b) Inability to pay
c) No appointment was available
d) No access for people with disabilities
e) No insurance
f) No transportation
g) No child cares
h) Provider did not speak my language
i) Others please specify ________________________
10. What health issues have you or a family member had in the last year?
a) Aging problems (Arthritis, hearing/vision loss, etc.)
 SALINAS WESTPOINT COLLEGE INC.
2nd Floor 248 SS Abutin Bldg., General Trias Drive, Tejeros Convention Rosario, Cavite, 4106
Tel. No. (046) 477-2675 E-mail address: salinaswestpointcollegeinc@gmail.com

b) Allergies
c) Cancers
d) Dental problems
e) Diabetes
f) Dog Bites
g) Firearm-related injuries
h) Heart disease and stroke
i) High blood pressure
j) Liver disease
k) Motor vehicle crash injuries
l) Respiratory/lung disease
m) Others please specify ________________
11. In your opinion do you agree that you are capable of dealing with your child's
emotions appropriately?
12.How capable do you think you are to support your child's learning at home?
C. COMMUNITY & ENVIRONMENTAL ISSUES
1. I believe the following issues exist in my community applies
a) Air pollution
b) Exposure to tobacco smoke
c) Lack of safe recreational areas
d) Open dumping
e) Septic System run-off
f) Unsafe drinking water
g) Unsafe river/creek/stream water
h) Unsafe roads, highways
i) Others please specify ________________________________
2. What are the three environmental health issues you think are the biggest concern
in your community?
a) ______________________________________________________________
b) ______________________________________________________________
c) ______________________________________________________________
 SALINAS WESTPOINT COLLEGE INC.
2nd Floor 248 SS Abutin Bldg., General Trias Drive, Tejeros Convention Rosario, Cavite, 4106
Tel. No. (046) 477-2675 E-mail address: salinaswestpointcollegeinc@gmail.com

3. Do they have school,health care center and what other facilities are available?
4. Are you good at building a healthy relationship and communicating with your
neighborhood?

D. WASTE MANAGEMENT
1. Does your household or barangay follow any proper waste management?
2. How many times is your trash collected?
3. Do you follow the “Tapat ko, Linis ko”?
4. Did you participate every time there is a clean-up drive in your barangay or
community?
5. What are the problems you encountered in your barangay regarding trash?
6. Does your barangay maintain the cleanliness of the surrounding?
7. Does your barangay hall provide proper waste trash cans?

Prepared by: Noted by:

John Carlo C. Loremia Ms. Mary Ann A.Nacpil

Group Leader / SSC President College Dean