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Updated HH Profiling Forms060623
Updated HH Profiling Forms060623
com/yv8mwnuw
Summary 4Ps Non-4Ps Unknown Total Water Source 4Ps Non-4Ps Unknown Total
HouseHold 0 0 0 0 Level I 0 0 0 0
Family 0 0 0 0 Level II 0 0 0 0
Toilet Facility 4Ps Non-4Ps Unknown Total Level III 0 0 0 0
Sanitary Toilet Facility Unknown 0 0 0 0
Pour/flush toilet connected to septic 0 0 0 0 Philhealth Category
tank
Pour/flush toilet connected to
connected to septic tank & to 0 0 0 0 Direct Contributors 0
sewerage system
Ventilated improved pit latrine (VIP) 0 0 0 0 Indirect Contributors 0
Unsanitary Toilet Facility Unknown 0
0 0 0 0 Sex Ethnicity
Water-sealed connected to open drain
Overhung latrine 0 0 0 0 Male 1 IP's 0
Open-pit Latrine 0 0 0 0 Female 0 Non IP's 0
Without toilet 0 0 0 0 Total 1 Total 0
Educational Attainment 4Ps Non-4Ps Unknown Total Single Married Live in Widow/er
Pre-school 0 0 0 0 Civil Status 0 0 0 0
Elementary Undergraduate 0 0 0 0 Separated 0 Cohabitation 0
Elementary Student 0 0 0 0 Religion
Elementary Graduate 0 0 0 0 Roman Catholic 0 Pentecostal 0
High School Under Graduate 0 0 0 0 Christian 0 Unknown 0
High School Student 0 0 0 0 Iglesia ni Cristo 0 Others 0
High School Graduate 0 0 0 0 Catholic 0
Senior High School 0 0 0 0 Islam 0
ALS - Advance Learning System 0 0 0 0 Baptist 0
College Undergraduate 0 0 0 0 Born Again Christian 0
College Graduate 0 0 0 0 Buddhism 0
College Student 0 0 0 0 Church of God 0
Post Graduate/ Masteral/ Doctorate 0 0 0 0 Jehovahs Witness 0
Vocational Course 0 0 0 0 Protestant 0
N/A 0 0 0 0 Seventh Day Adventist 0
Family Planning Methods 4Ps Non-4Ps Unknown Total LDS-Mormons 0
COC 0 0 0 0 Envangelical 0
POP 0 0 0 0 Medical History Male Female Total
Injectibles 0 0 0 0 Hypertension 0 0 0
IUD 0 0 0 0 Diabetes Melitus 0 0 0
Condom 0 0 0 0 Tuberculosis 0 0 0
LAM 0 0 0 0 Others 0 0 0
BTL 0 0 0 0 Age Group Male Female Total
Implant 0 0 0 0 1-28 days 0 0 0
SDM 0 0 0 0 29-11mos 0 0 0
DPT 0 0 0 0 1-4 year old 1 0 1
Withdrawal 0 0 0 0 5-9 years old 0 0 0
Others 0 0 0 0 10-14 years old 1 0 1
15-19 years old 0 0 0
Classification by Age/Health Risk Group
20-24 years old 0 0 0
Male Female Total 25-29 years old 0 0 0
N - Newborn (0-28 days) 0 0 0 30-34 years old 0 0 0
I - Infant (0-1 y/o) 0 0 0 35-39 years old 0 0 0
PSAC (1-4 y/o) 0 0 0 40-44 years old 0 0 0
SAC - School Age (5-9 y/o) 0 0 0 45-49 years old 0 0 0
Ad - Adolecent (10-19 y/o) 0 0 0 50-54 years old 0 0 0
A - Adult (20-59 y/o) 0 0 0 55-59 years old 0 0 0
SC - Senior Citizen 0 0 0 60-64 years old 0 0 0
65-69 years old 0 0 0
>70 years old 0 0 0
Approved by:
___________________________________
Name and Signature
n
HOUSEHOLD PROFILING FORM
Instructions link: https://tinyurl.com/yv8mwnuw 1. Date of Visit (yyyy-mm-dd)
Relation
Household No.* -ship of Write the birthday Classification by Type of Type of
Date of Visit* Age in years Civil Educational Philhealth ID M - Member DC - Direct HPN -
(yyyymm-Facility Barangay* (Please provide the names of the members of the household members in this date format:
and months*
Sex*
Status*
Religion D - Dependent Contributors Hypertension Age/Health Risk Water Toilet
(yyyy-mm-dd) to HH
Attainment Number
Group* Source* Facility*
Code-No.(00000)) starting from the household head followed by spouse, yyyy-mm-dd Yes/NO. If Yes.
IC - Indirect DM - Diabetes If Pregnant,
Family
son/daughter (eldest to youngest), and other members) Head* Contributors TB - Tuberculosis Write the LMP in Using any FP FP Status (if
IPs or Non-IPs Ple indicate 4Ps Planning
U - Unknown O -Others (pls. specify) this date format: method? Y/N applicable)*
Houshold ID No. Method used
yyyy-mm-dd
Last Name* First Name* Middle Name*
All information provided are strictly confidential pursuant to Section 10 (Confidentiality of Information) of Republic Act (RA) No. 11315 and the Data Privacy Act of 2012. This will not be used against you or to any of your household members for taxation, investigation, or law enforcement purposes.
Legends:
Sex/Gender Civil Status Educational Attainment Religion Classification by Age/Health Risk Group Family Planning Methods Family Planning Status Type of Water Source Type of Toilet Facility:
Members of Household
1 - Head M - Male M - Married N - None SH - Senior H/S - Roman Catholic - Christian - LDS-Mormons N - Newborn (0-28 days) COC SDM NA - New Acceptor Lv I - Point Source Sanitary Toilet Unsanitary Toilet
2 - Spouse F - Female S - Single PS - Pre-school ALS - Adv Learning System - Christian - Buddhism - Envangelical I - Infant (0-1 y/o) POP DPT CU - Current User Lv II - Communal faucet P - Pour/flush toilet connected WS - Water-sealed connected
3 - Son W - Widow/er ES -Elem Student V - Vocational Course - INC - Church of God - Pentecostal PSAC - 1-4 y/o Injectables Withdrawal CM - Changing Method system or stand posts to septic tank to open drain
4 - Daughter SP - EU - Elem Undergrad CS - College Student - Catholic - Jehovahs Witness - Unknown SAC - School Age (5-9 y/o) IUD Others (pls. CC - Changing Clinic Lv III - Waterworks system or OH - Overhung Latrine
5 - Others, specify relation Separated EG - Elem Graduate CU - College Undergrad - Islam - Protestant - Others (pls. Specify) Ad - Adolecent (10-19 y/o) Condom specify) DO - Dropout individual house connection PF - Pour/flush toilet OP - Open-pit Latrine
C- HS - HS Student CG - College Graduate - Baptist - Seventh Day Adventist A - Adult (20-59 y/o) LAM R - Restarter O - For doubtful sources, connected to septic tank and WO - Without toilet
Cohabitation HU - HS Undergrad PG - Postgrad/ Materal/ - Born Again SC - Senior Citizen BTL open dug well etc. to sewerage system
HG - HS Graduate Doctorate Implant VIP - Ventilated improved pit
latrine (VIP) or composting
toilet