BARANGAY MANAGEMENT INFORMATION SYSTEM 9. Do you use iodized salt (Gumagamit 17.

Structure of the 1 5
FAMILY DATA SHEET ng iodized salt)? ☐ Yes (Oo) ☐ No (Hindi) house: 2
Duplex
Commercial/Industr 6
Multi-Unit Residence
Single House
10. Do you practice Family Planning
CERTIFICATION
I hereby certify that the data gathered in this questionnaire was (Gumagamit ng family planning)? ☐ Yes (Oo) ☐ No (Hindi) “Kaanyuhan ng bahay”
3
ial/ Agricultural
Extension
7 Other Housing Unit

obtained/checked by me personally according to the instructions given. ☐ Not applicable (Hindi 4 Institutional Living
Quarters
naaayon)
11. If yes, what method/s of family planning (Kung oo, ano paraan ng 18. External housing 1 Asbestos/Glass/Others
Name and Signature of Enumerator Date Signed
family planning ang ginagamit)? walls: 2 Bamboo, Sawali, Cogon, Nipa
Natural Artificial “Uri ng yari ng dingding 3 Concrete/Brick/Stone
Name and Signature of Respondent Date Signed 1 Basal Body Temperature 8 Condom ng bahay” 4 Galvanized Iron, Aluminum
2 Cervical Mucus 9 Depo Injection 5 Half-Concrete, Brick, Stone, Half Wood
FAMILY IDENTIFICATION 3 Lactational Amenorrhea Method 10 IUD 6 Makeshift, Salvaged, improvised
Pangalan ng Puno ng Pamilya 4 Rhythm 11 Ligation 7 Wood
First name: Middle name: 5 Standard Days Method 12 Pills 8 No walls/not reported
Last name: Qualifier: 6 Sympto-thermal Method 13 Vasectomy 19. Roof construction 1 Bamboo, Sawali, Cogon, Nipa
7 Withdrawal 14 Others 2
Address material: Galvanized/iron
ENVIRONMENT AND SANITATION
House No.: Street/Subd: “Materyales ng bubong 3 Makeshift, Salvaged, improvised materials (ex.
12. Toilet facilities: Type 1 Owned solely 2 Shared
Purok: Barangay: “Uri ng by family ng bahay” plastic/sack/tarpaulin)
palikuran” 1 Water sealed with 4 Mixed materials but more of
Municipality: Province: sewage/septic tank
❑ ❑ cogon/nipa/anahaw
Household Condition Family Status
2 Covered Pit ❑ ❑ 5 Mixed materials but more of Galvanized/iron
3 Open Pit ❑ ❑
❑ Resident ❑ Owner (main family) ❑ Active 4 Thrown Anywhere ❑
20. Floor material - first 1 Bamboo 5 Wood
❑ Non-resident ❑ Extended ❑ Inactive 5 Others (Pail
floor: 2 Cement 6 Soil
System, Etc.)
❑ “Materyales ng sahig ng 3 Cemented with 7 Soil with linoleum
FAMILY INFORMATION 1 Owned solely bahay- unang linoleum
13. Source of water: 2 Public 3 Shared
1. No. of family members (Bilang ng Miyembro ng pamilya)? by family palapag” 4 Cemented with tiles
“Pinagkukunan ng
2. Year first resided in the brgy (Unang taon nanirahan ang tubig” 1 Dug well ❑ ❑ ❑
2 Community water 21. Lighting used: 1 Battery
Electricity
puno ng pamilya sa Brgy)?:
system
❑ ❑ ❑ “Pailaw na ginagamit sa 2 Candle
*Check all that
3. Household heads place of origin before 3 Tubed piped, deep bahay” 3 Solar power
applies.
well
❑ ❑ ❑ 6.1 With electric meter
living in the brgy (Lugar na Pinanggalingan 4 Kerosene 6.2 Without electric
ng Puno ng Pamilya)? (Municipal, Province) 4 Tubed piped,
shallow well
❑ ❑ ❑ Others, specify: meter
_________________
4. Contact number of the head of the family: 5 Spring, lake, river,
rain
❑ 22. Cooking facilities: 1 Charcoal
Telephone service provider Contact number (Landline/Mobile) 4 LPG
6 Peddler ❑ “Ginagamit sa pagluluto” 2 Electricity
5 Wood
7 Buy mineral water ❑ 3 Kerosene
8 Others: 23. Garbage disposal: 1 Burned 5 River
14. Source of electricity: 1 Barangay generator Power producer/ “Paraan ng pagtatapon 2 Collected 6 Thrown anywhere
5. Type and number of vehicle owned (Uri at bilang ng pag-aaring “Pinagkukunan ng 2 Battery cooperative, specify: ng basura” 3 Composting 7 Waste
kuryente/enerhiya” 3 Biogas 4 Open Pit Segregation
sasakyan)? ____________________
4 Own generator 24. Location of house: Along the:
Vehicle (Sasakyan) Number Vehicle Number 6 None
*Check all that applies. 5 Solar 1 Irrigation canal
(Bilang) (Sasakyan) (Bilang) “Lugar na kinatatayuan National/Provincial road
1 Bicycle 9 Pedicab 15. House 1 Owned ng bahay” 2 Lakeshore 11 Along (0-10m)
acquisition: 2 Rented 3 Railroad 12 Near(11-500 m)
2 Boat 10 Pick-Up “Pagmamay-ari ng 3 Being Amortized (hinuhulugan)
4 Riverbank 13 Far (>500 m)
3 Bus 11 Pump Boat bahay” 4 Being occupied for free with consent (nakatira ng
libre na may pahintulot) 5 Seashore
4 Car 12 Raft
5 Being Occupied for free without consent (nakatira Foot of: Municipal road
5 Jeepney 13 SUV 6 Hill
ng libre na walang pahintulot 14 Along (0-10m)
6 Motorboat 14 Tricycle 6 Caretaker (taga-bantay ng bahay) 7 Mountain 15 Near(11-500 m)
7 Motorcycle 15 Truck 7 Family owned (pagmamay-ari ng pamilya) 16 Far (>500 m)
8 Owner Type Jeep 16 Van 8 Government owned (pagmamay-ari ng gobyerno) 8 On a hill Barangay road
16. Lot ownership: 1 Owned 17 Along (0-10m)
9 On the mountain
HEALTH INFORMATION “Pagmamay-ari sa 2 Rented 18 Near(11-500 m)
lupa” 3 Being Amortized (hinuhulugan) 10 Rice field 19 Far (>500 m)
6. Do you plant herbal plants (May
tanim na halamang gamot)? ☐ Yes (Oo) ☐ No (Hindi)
4 Being occupied for free with consent (nakatira ng
libre na may pahintulot)
20 Others (waiting shed, under the bridge, cart,
etc.)
5 Being Occupied for free without consent (nakatira
7. If yes, what herbal plants (Kung ng libre na walang pahintulot 25. Location of house
Oo, anong uri ng halamang gamot)? 6 Caretaker (taga-bantay ng bahay) according to 1 Coastal 2 Lowland 3 Upland
8. Do you have a vegetable garden 7 Family owned (pagmamay-ari ng pamilya) “ecological setting”:
(May tanim na gulay)? ☐ Yes (Oo) ☐ No (Hindi) 8 Government owned (pagmamay-ari ng gobyerno)