AGRICULTURAL INFORMATION:

26. Kabuuang laki ng lupang sinasaka at lugar: 32. Uri ng Palaisdaan 1 Freshwater 2 Freshwater 3 Brackish water 4 Marine fish 5 Backyard
Kalagayan sa Pag-aari ng Lupang (Type of Aquaculture Farm) cage/pen fishpond fishpond cage/pen
Kapag tenant, sino ang
Lawak (ektarya) Lugar ng lupang sinasaka Sinasaka (Status of Ownership in the Farm
may-ari ng lupa
(If Farming): Owned, Leased, Tenanted
33. Uri ng Kagamitan/makinarya sa pagsasaka 35. Hayop na Pangkain na inaalagaan (Farm Animals Raised)
(Agricultural Machineries/Equipment/ToolsOwned): Animals # of Animals # of Animals # of
Machineries Bilang Machineries Bilang Heads Heads Heads
Rice mill 4-wheel tractor Baboy (barako) Kabayo Pugo
Feedmill Sprayer (Knapsack) Baboy (inahin) Kalabaw Itik
Agricultural/Fishery Products: Grain Drying Facility Sprayer (Power) Baboy (biik) Kambing Manok (layer)
28. Uri ng Lupang Sinasaka 29. Lawak ng lupa bawat pananim Warehouse Araro Baboy (grower) Bengala Manok
(Type of Farm) 30. Lugar Thresher Suyod (broiler)
27. Pananim/ Produkto (Product) Kabuuang laki Bilang ng Puno ng
Irrigated, Rainfed, Upland, (Brgy/Mun/Prov)
(ektarya) pananim Reaper Waterpump Baka Tupa Manok (native)
Lowland Others, specify
Corn Sheller Hand tractor Bibi Pabo Manok
(sasabungin)
34. Uri ng Kagamitan/makinarya sa pangingisda 36. Pet Animals
(Fishing Machineries/ Equipment/ Tools Owned: #of #of # of
Machinery Bilang Machinery Bilang Animals Animals Animals
Heads Heads Heads
Sima o pangawit (barb) Motorized Fishing Boat Dog/Puppy Rabbit Fish
31. Kalagayan sa pag-aari ng
4 Fishpond Leasehold Cat/Kitten Monkey
palaisdaan (Status of Aquaculture 1 Owned 2 Leased 3 Tenanted Lambat 3 tons pababa (mun fishing vessel)
Agreement (FLA)
Farm Ownership) Bird Snake
Non-motorized Fishing Boat 3 tons pataas (commercial)
FAMILY MEMBERS INFORMATION:
Status (If Registered Buntis
Relation Main Other Type of
Name dead, write Birthday Place of Registered COMELEC Place of Civil Organi- Name of Educational Status of Degree/ Status Country/ Monthly (Yes
to HH Sex Religion Skills Ethnicity Studying Source of Sources of Sakit Kapansanan Health
(First/ Middle/ Last) cause of (mm/dd/yr) Birth Birth at Civil Voter in the Registration Status zations School Level Schooling Course of Work OFW Place of Income or
Head (4) (11) (12) (14) (15) Income Income (26) (27) Insurance
(1) death) (5) (6) Registrar barangay (9) (10) (13) (16) (17) (18) (19) (21) (22) Work (25) No)
(2) (20) (24) (28)
(3) (7) (8) (23) (29)
1.
HH
2.

3.
4.
5.

6.

7.

8.

9.

10.

(2) Relation (8) (10) (14) (17)

10. Live in (3) (4) (5) (6) (7) (9) M-Married; Mga Hal.: (15) Write (18) (19) (20) (21) (22) If OFW, (25) (28)
1. Adopted 11. Niece/Nephew Yes–if
A–Active M-Male Write Write Yes- registered Write NM- Not abilidad Bicol Yes- NS - No G- Write Write actual P- Write Y write Add see below
2. Brother/Sister 12. Others T- F- complete Municipal Registered in the brgy Barangay, Married/Co Studying Schooling Graduate course if work if OFW country income selections
Brother-in-law 13. Parent/s mmon law Ibanag Perman
Transferred Female year and Birth
3. Child (Anak) 14. Parent-in-Law No–if not Municipality spouse halimbawa Ilocano NYS- Not Yet UG-Under- college
ent
where of main
D-Died i.e. Province and welding, Ivatan No - Not Studying graduate graduate working and
4. Daughter/Son 15. Relative registered S-Single
1/25/2015 No-Birth in the brgy Province SP-Solo singing, Studying DC-Day Care S- NP- Not other
in-law 16. Sister-in-law Moro
5. Employee 17. Spouse not Parent W- carpentry, Pangasine or not yet K-Kinder Studying Perman sources
NR-if not
6. Grandchild 18. Step registered registered Widow dancing nse studying Gr 1, 2…12 ent of
(Apo) Son/Daughter in any brgy LS-Legally Sambal Elementary income
7. Grandparent/s 19. Step-Parent Separated
Tagalog 1st, 2nd…year
8. Head of the 20. Student NA- if not A-Annulled
yet voter Visayan at college or HS
Family Sep-
9. Housemaid (age 0–17 Separated iba pa.
yrs old)
(28) Health insurance: 1 No health insurance; 2 Active member of PhilHealth w GSIS (Philippine government) ; 3 Active member of PhilHealth w SSS (private companies); 4 Active member of OWWA; 5 Active member self-paying Philhealth; 6 Present member of PhilHealth non-paying member;
7 Active member of Health maintenance; 8 Active member community/ cooperative health scheme Organization; 9 Active member private health insurance; 10 Dependent health insurance; 11 Local Health insurance Halimbawa: health insurance na ginagamit lang sa mga ospital ng probinsya o
munisipyo; 12 Present member of Philhealth LGU halimbawa: 4Ps beneficiary, PNOY; 13 Philhealth member dependent
HEALTH INFORMATION FOR CHILDREN AGED 0-71 MONTHS:
Date last 2 Vit. A 3 Vit. A 4 Vit. A 1 Presently 2 Presently BF
Name 1 BCG 2 Pentavalent1 3 Pentavalent2 3 Pentavalent3 4 OPV1 5 OPV2 6 OPV3 7 HVB1 8 HVB2 9 HVB 3 10 AMV 11 MMR 1 Iron Exclusively BF
dewormed (April) (Oct.) (when sick)