Lahore School of Nursing

The University of Lahore

BASELINE SURVEY FORM OF COMMUNITY ASSESSMENT

1. Name of the area:

………………………………………………………………………………
2. RURAL/URBAN…………………………….
…………………………………………………..
3. Boundaries:………………………………………………….
……………………………………
4. Name of Health Centre:
………………………………………………………………………….
5. Name of the head of family: ………………………………………………….………………
6. Type of family: Nuclear …………………………Joint………………..……………….
7. Religion: Muslim/ Non Muslim ………… (SPECIFY THE SUB CAST)………………..
…...
MUSLIM…………… (SPECIFY THE SUB CAST) ……………..…..…..
CHRISTIAN………...(SPECIFY THE SUB CAST) ……………....……..
ANY OTHER………. (SPECIFY THE SUB CAST)
……………………..
8. Housing condition:
1 Type of house PACCA SEMI PACA KACCHA
II Rooms: NUMBERS ADEQUATE INADEQUATE
III Occupancy: TENENT OWNER MONTHLY RENT
IV Ventilation: ADEQUATE INADEQUATE NO VENTILATION
V Lighting: ELECTRICITY GAS LAMP OIL LAMP
VI Water supply: TAPE HANDPUMP WELL OPEN TANK
VII Kitchen: SEPARATE CORNER OF THE ROOM VERANDA
VII Drainage: ADEQUATE INADEQUATE NO DRAINAGE
I
IX Lavatory: OWN LATRINE PUBLIC LATRINE OPEN AIR DEFECATION
X Lawn OWN AT HOME PUBLIC LAWN FIELDS

9. FAMILY COMPOSITION:
Sr# Name Relationship with head Age Sex Education Occupation Income
1
2
3
4
5
6
7
8

1
10. Total income of the family:
I Below 10000 IV Between 30001-40000
II Between 10001-20000 V Above 40000
II Between 20001-30000
I
11. Education status: Number of Persons
I. Not literate ……………………………
II. Primary education ……………………………
III. Middle school ……………………………
IV. High school ……………………………
V. Pre-University Course ……………………………
(Pre Degree Course)
VI. Graduate ……………………………
VII. Post graduate ……………………………

12. Transport and communication media:

I Transport IV Uses private buses
II Owns vehicles V Train
III Uses company buses VI Aero planes

Communication & Mass media:

I Telephone (Mobile/ Public) V Post and telegraph
II Television VI E.mails
III Radio VII Loudspeakers/Announcements
IV Newspaper/magazine VIII

I. Language: Language Known:

I. Mother tongue English
II. Urdu Sindhi
III. Sindhi Urdu
IV. Punjabi Punjabi
V. Balochi Baloochi
VI. Pashtoo Pashtoo
VII. Specify others

13. Dietary Pattern:

Food available Food used Food preparation and storage
Traditional Ideal Unhygienic Hygienic
Rice
Ragi
Jawar
Wheat
Vegetable

2
 Fish
Meat
Egg
Milk and milk
products
pulses

Tubers

14. Statement of Expenditure of Family:

Sr# Items Amount spent Percentage of total
(approximate) expenditure
1 Food
2 Clothing
3 Housing (Rent)
4 Medicine
5 Children education
6 Recreation (movies, games
etc.)
7 Smoking/ Liquor etc
8 Debt
9 Savings
10 Others

15. Is there any case of fever (if yes write detail in below table)
I. Rigors
II. Cough
III. Rash
IV. Others
Sr Name Age Disease Treatment Remarks
#
1
2
3
4

16. Does anyone have any type of skin disease (Itching, patches, rashes etc)?
Sr Name Age Disease Treatment Remarks
#
1
2
3
4

17. Does anyone have cough more than two weeks?

3
 Sr Name Age Disease Treatment Remarks
#
1
2
3
4

18. Does anyone have any other illness?

Sr Name Age Disease Treatment Remarks
#
1
2
3
4
19. Are they having any health problem?
Sr Name Age Disease Treatment Remarks
#
1
2
3
4
20. Are any women pregnant if yes then write following codes?
I. Gravida (1st :a, 2nd : b, more than 2: c)
II. Has she been registered in health center?
III. Is she getting iron and folic acid?
IV. Has she had tetanus toxid?
V. Others
Sr Name I. II. III. IV. V.
#
1
2
3
4

21. Have there been any vital statistics of birth?

Sr Date of birth Sex Patient’s Treatment Remarks
# Name
1
2
3
4
22. Have there been any vital statistics of death?
Sr# Patient’s Name Sex Date of death Treatment Remarks
1
2

4
 3
4
23. Have there been any vital statistics of marriages?
Sr# Name Age Date of marriage Remarks
1 Bride
Bridegroom
2 Bride
Bridegroom

24. Are there any children below five years who have not received immunization (Specify
name, age and reason for not being immunized)
I. BCG Vaccination
II. DPT Vaccination
III. Poliomyelitis Vaccination
IV. Measles Vaccination
V. Vitamin A drops
Sr Name Age Sex I. II. III. IV. V. Remarks
#
1
2
3
4
5
6
7
8
25. Special note if needed:
___________________________________________________________________________
___________________________________________________________________________
26. Is there any eligible couple (if yes then list on priority)
I. PS= Primary sterility
II. SS= Secondary sterility
III. EP= Early menopause
IV. Using a contraceptive method. If yes then specify type______________________
V. Interested to undergo for: Vasectomy Tubal Ligation
VI. If not interested to adapt family planning methods then state the reasons
______________________________________________________________________________
______________________________________________________________________________
________
Sr# Name Age Sex Priority-I Priority-II P SS EM Remarks
S
1
2
3
5
 4

27. Is there any child between 0-5 years in family who shows signs of malnutrition?
I. Kwashiorkor?
II. Marasmus?
III. Vitamin A deficiency?
IV. Anaemia?
V. Rickets?

Sr# Name Age I. II. III. IV. V. Remarks

1
2
3
4
5
6
7

28. Is the sullage water being disposed of hygienically? (If yes tick any one/all)
i. Drain ii. Soak pit iii. Kitchen garden

If not then state the reason__________________________________________________

29. Is the rubbish being disposed off hygienically? (If yes tick any one/all)
i. Composing ii. Burning iii. Burying
If not then state the reason_________________________________________________
30. Is excreta being disposed off hygienically? Yes/No
If no then state the reason__________________________________________________
31. Are the cattle and poultry housed hygienically?
i. Separate ii. Within house
Then state the reason_____________________________________________________
32. Is there a well or hand pump?
i. Is it maintained in good order? Yes/No
If no then state the reason___________________________________________________
ii. When the well chlorinated last time? Mention the
date:____________________________
If Yes/No then state the reason_____________________________________________________
33. Whether the house is kept clean?
If Yes/No then state the reason_____________________________________________________
34. When house was sprayed last time? Mention the
date :____________________________
If Yes/No then state the reason_____________________________________________________

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35. Is there breeding place of insects and rodents? Yes/No
36. Are there any stray dogs in the vicinity? Yes/No.
If yes then write approximate number of dogs.__________________
37. If anyone falls ill where do you get for treatment?
I. Hospital/Primary health centre
II. Sub centre primary health unit
III. Private nursing homes
IV. Indigenous doctor/ local quacker
38. Are official health agencies services adequate? Yes/No
If Yes/No then state the reason_____________________________________________________
______________________________________________________________________________

Note:
In addition to the above students are expected to obtain following information by observation
and other methods.
I. Description of the community location, topography, climate, history etc. Type of
government system, no. of schools and health care agencies. Infection control diseases
(ICDS) centers, place of worship (e.g. Masjid, Church) and any other information related
to health.
II. List of target couple with details on priority basis.
III. Maintain record of road to health Card for knowing the degree of malnutrition under
5years wherever necessary and use if need of nutritional assessment from prompt.
IV. Use problem solving approach/ construct good nursing care plan.
V. Remarks can be written in separate sheets quoting code.

_____________ ________________________
Date of survey Name and signature of student

Faculty Signature

Definition: Tubers are basically swollen, underground plant parts that store food. There are two
types of tubers:

1. Root Tuber An enlarged root that stores food for the plant and from which shoots will
grow.
2. Stem Tuber The enlarged tip of a food storing rhizome or underground stem.
3. Sullage - Waste from household sinks, showers, and baths—but not toilets; it also
figuratively means filth or refuse.

References:

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Basavanthappa, B. T. (1999). Community Health Nursing (1st ed.). New Delhi: Jaypee Brothers.