Saint Paul University Philippines

Tuguegarao City, Cagayan Valley 3500 I. Number of Pregnant Women:

● AGE <15
DATA BASELINE SURVEY FORM • Age 15 – 19: ___ • Age 20 – 24: ____
• Age 25 – 29: ___ • Age 30 – above: ____
Zone: 7 Household No: 0065 • Others, specify: ______
Date of Assessment: March 17, 2022
Name of Assessor: Rica Jane Garcia J. Housing:
• Age of House:
Head of the Family: Elvira Fillon 0-5 6-10 11-15
* Materials used:
A. Family Size: • Concrete • Wood • Bamboo • Mixed
Number of Adults: Male: 2 Female: 1 * Number of floors:
Number of Children: Male Female • One • Two • Three • Four
* Lighting Facility:
B. Marital Status: • Electric Bulb • Candles • Gas Lamps
• Single: Male: 1 Female * General State of Repair:
• Married:2• Widow: ___ • Widower: ___ • Roof • Floor • Walls • Ladder • Window • Door
• Separated: ___ • Foundation • Roof Braces • Rooms • Sink
• • Kitchen • Toilet • Others: __________________

C. Educational Attainment: K. Hangouts:

• Elementary Undergraduate: ___ Male ___ Female
• Elementary Graduate: ___ Male ___ Female
• Highschool Undergraduate: __1_ Male Female
• Highschool Graduate: _1__ Male __1_ Female
• College Undergraduate: Male Female
• College Graduate: ___ Male Female
• TechVoc Course Graduate: Male ___ Female
• Store • Waiting Shade • Court • Yards • House
•Others: __________________
L. Animals:
• Dogs:8 • Cats: 3 • Pig:5 • Chicken: _12__
• Duck: 15 • Bird: _2__ • Goat: __10_ • Carabao: 2
• Cow: __1_ • Others: _________

D. Occupation: M. Water (drinking):

• Farmer: 1• Carpenter: ____ • Housewife: 1• Driver: * Source: • Faucet • Deep Well • Pump Well
• OFW: • Others, specify: Mineral water supply
• Others, specify: STUDENT 1 * Ownership: • owned• shared
* Storage: • Refrigerated • Not refrigerated
_________________ • Covered • Not covered
M. Water (general usage):
E. Religion: * Source: • Faucet • Deep Well • Pump Well
• Roman Catholic: _3___ • Baptist: _____ • Others, specify: ______________
• Born Again:• Others, specify • Drum • Jags • Bottles • Pail • Jar
* Storage: • Refrigerated • Not refrigerated
F. Types of Family: • Covered • Not covered
• Dyad • Nuclear • Extended • Drum • Jags • Bottles • Pail • Jar
• Blended • Single Parent * Usage: • Bathing • Cooking • Laundry

G. Authority: N. Food:
a. Decision Making: * Cooking facility: • Firewood • Gas stove • Charcoal
• Patriarchal • Matriarchal • Egalitarian • Electric Stove • Others: ________
b. Child Discipline: * Storage: • Refrigerated • Not refrigerated
• Patriarchal • Matriarchal • Egalitarian • Covered • Not covered
c. Healthcare Decisions: * Usual Number of Meals per day:3
• Patriarchal • Matriarchal • Egalitarian * Usual Composition:
d. Financial Management: • Vegetable • Fish • Chicken • Meat • Fruits • Rice
• Patriarchal • Matriarchal • Egalitarian •pork •beef •others

O. Exercise:
• Yes: ____ • No:/
* Types:
H. Signs and Symptoms: • Jogging: ___ • Walking: 3 • Work: ___
• Head ache: _/__ • Colds: • Cough: ___ • Fever: ___ • Biking: ___ • Stretching: ___ • Others: __________
• Others, specify: __________
• Hypertension: ___ • TB: ___ • DM: ___
• Others, specify: __________ __________ P. Vices:
• Diagnosed by a practitioner? • Yes: ___ • No: /__
• Smoking: ______
• Drinking Alcohol: ______
Q. Leisure and Recreation:
• Chatting: / • Listening to radio: _/__ • Sports: ___
• Sleeping: / • Walking: _/_ • Watching TV: _/_
• Playing cards: ___ • Others: _________________
• Others: ________________________________
* Level of Satisfaction:
• Very Satisfied • Satisfied • Not Satisfied
* Frequency of Visiting Healthcare Facilities:
• Once • Twice • Thrice • As needed

R. Toilet: * Name of Healthcare Provider/s:

* Ownership: • owned • shared 1. _______________________________________
* Type: • Flush • Pail system 2. _______________________________________
• Open pit • Close pit • Water sealed 3. _______________________________________
* Distance: • 2 – 3M • 4 – 5M • 6 – 7M
• 8 – 9M • 9 – 10M • 11 – above * Reasons for Visiting Health Centers:
• Health Education • Check – up • Medicine
S. Garbage: • Feeding Program • Others: _________________
* Container used: • Trashcan • Plastic • Sack
• Box • Pail • Hole * Name of Organizations:
* Method: • Burning • Composting • Open dumping 1. _______________________________________
* Waste Segregation: • Yes • No 2. _______________________________________
3. _______________________________________
T. Drainage System:
* Type of Drainage: • Open • Close
* Household drainage: • Open • Close • None

U. Transportation:
• Jeepney • Truck • Motorcycle • Tractor NOTES:
• Tricycle • Van • Other: _____________
DOCUMENTATION:
V. Income:
* Who earns? • Mother • Father • Both Parents
• Children • All
* Source: • Farming • Self- employment
• Pensions • Others: _____________________
* Monthly income: • 0 – 500 • 501 – 1000
• 1001 – 2000 • 2001 – 3000
• 3001 – 4000 • 4001 – 5000 • 5001 – above
* Expenditure: • Clothing • Education • Food • Farm
• Housing • Medicine • Others: ______________
* Products: • Rice • Corn • Vegetables
• Poultry • Others: ____________
* Land ownership: • Tenant • Owned

W. Other Information:
* Protective Services Available:
• Police • Army • Tanod •security guard :

* Security Facilities Available:

• Streetlights • Road humps • CCTV • Others:
__________

* Social Facilities Available:

• Courts • Waiting shades • Others: ____________

* Healthcare Facilities Available:

• Botika • Health Center • Others: ____________

* Healthcare Providers Present:

• Nurse • Doctors • Midwives
• Trained Hilot • Albularyo • Others: ____________

* Health Services Offered:

• Immunization • Health Education • Check – ups
DATA BASELINE SURVEY FORM
Zone: 7 Household No:
Date of Assessment: March 17, 2022
Name of Assessor: Rica Jane Garcia
I. Number of Pregnant Women:
AGE <15
• Age 15 – 19: ___ • Age 20 – 24: ____
• Age 25 – 29: ___ • Age 30 – above: ____
• Others, specify: ______

Head of the Family: James Eslabra J. Housing:

• Age of House:
A. Family Size: 0-5 6-10 11-15
Number of Adults: 1 Male 1 Female * Materials used:
Number of Children: 1 Male 2 Female • Concrete • Wood • Bamboo • Mixed
* Number of floors:
B. Marital Status: • One • Two • Three • Four
• Single: __1_ Male 2 Female * Lighting Facility:
• Married: 2 • Electric Bulb • Candles • Gas Lamps
• Widow: ___ • Widower: ___ * General State of Repair:
• Separated: ___ • Roof • Floor • Walls • Ladder • Window • Door
• • Foundation • Roof Braces • Rooms • Sink
• Kitchen • Toilet • Others: __________________
C. Educational Attainment:
• Elementary Undergraduate: 1_ Male 2 Female K. Hangouts:
• Elementary Graduate: ___ Male Female • Store • Waiting Shade • Court • Yards • House
• Highschool Undergraduate: ___ Male Female •Others: __________________
• Highschool Graduate: ___ Male ___ Female
• College Undergraduate: ___ Male ___ Female L. Animals:
• College Graduate: _1_ Male _1__ Female • Dogs: ___ • Cats: • Pig: __2_ • Chicken: __14_
• TechVoc Course Graduate: ___ Male ___ Female • Duck: __10_ • Bird: ___ • Goat: __5_ • Carabao:
1___
D. Occupation: • Cow: ___ • Others: _________
• Farmer: ____ • Carpenter: ____ • Housewife: •
Driver: ____ • OFW: ____ M. Water (drinking):
• Others, specify: TEACHER 1 * Source: • Faucet • Deep Well • Pump Well
STUDENT • Others, specify: ___Mineral water
_Criminology1________________ service___________
* Ownership: • owned• shared
E. Religion: * Storage: • Refrigerated • Not refrigerated
• Roman Catholic: • Baptist: _____ • Covered • Not covered
• Born Again: 5 • Others, specify M. Water (general usage):
* Source: • Faucet • Deep Well • Pump Well
F. Types of Family: • Others, specify: __
• Dyad • Nuclear • Extended • Drum • Jags • Bottles • Pail • Jar
• Blended • Single Parent * Storage: • Refrigerated • Not refrigerated
• Covered • Not covered
G. Authority: • Drum • Jags • Bottles • Pail • Jar
a. Decision Making: * Usage: • Bathing • Cooking • Laundry
• Patriarchal • Matriarchal • Egalitarian
b. Child Discipline: N. Food:
• Patriarchal • Matriarchal • Egalitarian * Cooking facility: • Firewood • Gas stove • Charcoal
c. Healthcare Decisions: • Electric Stove • Others: ________
• Patriarchal • Matriarchal • Egalitarian * Storage: • Refrigerated • Not refrigerated
d. Financial Management: • Covered • Not covered
• Patriarchal • Matriarchal • Egalitarian * Usual Number of Meals per day: __3____
* Usual Composition:
• Vegetable • Fish • Chicken • Meat • Fruits • Rice
•pork •beef •others

H. Signs and Symptoms: O. Exercise:

• Head ache: __1_ • Colds: • Cough: • Fever:
• Others, specify: __________
• Hypertension: ___ • TB: ___ • DM: ___
• Others, specify: __________ __________
• Diagnosed by a practitioner? • Yes: ___ • No: __/_
• Yes: __/__ • No:
* Types:
• Jogging: ___ • Walking: 5 • Work: ___
• Biking: ___ • Stretching: ___ • Others: __________
P. Vices: * Health Services Offered:
• Smoking: ______ • Immunization • Health Education • Check – ups
• Drinking Alcohol: ____1__ • Others: ________________________________

Q. Leisure and Recreation: * Level of Satisfaction:

• Chatting: • / Listening to radio: /_• Sports: ___ • Very Satisfied • Satisfied • Not Satisfied
• Sleeping: •/ Walking:/• Watching TV: /___
• Playing cards: ___ • Others: _________________ * Frequency of Visiting Healthcare Facilities:
• Once • Twice • Thrice • As needed
R. Toilet:
* Ownership: • owned • shared * Name of Healthcare Provider/s:
* Type: • Flush • Pail system 1. _______________________________________
• Open pit • Close pit • Water sealed 2. _______________________________________
* Distance: • 2 – 3M • 4 – 5M • 6 – 7M 3. _______________________________________
• 8 – 9M • 9 – 10M • 11 – above
* Reasons for Visiting Health Centers:
S. Garbage: • Health Education • Check – up • Medicine
* Container used: • Trashcan • Plastic • Sack • Feeding Program • Others: _________________
• Box • Pail • Hole
* Method: • Burning • Composting • Open dumping * Name of Organizations:
* Waste Segregation: • Yes • No 1. _______________________________________
2. _______________________________________
T. Drainage System: 3. _______________________________________
* Type of Drainage: • Open • Close
* Household drainage: • Open • Close • None
NOTES:
U. Transportation: DOCUMENTATION:
• Jeepney • Truck • Motorcycle • Tractor
• Tricycle • Van • Other: _____________

V. Income:
* Who earns? • Mother • Father • Both Parents
• Children • All
* Source: • Farming • Self- employment
• Pensions • Others: TEACHING
* Monthly income: • 0 – 500 • 501 – 1000
• 1001 – 2000 • 2001 – 3000
• 3001 – 4000 • 4001 – 5000 • 5001 – above
* Expenditure: • Clothing • Education • Food • Farm
• Housing • Medicine • Others: ______________
* Products: • Rice • Corn • Vegetables
• Poultry • Others: ____________
* Land ownership: • Tenant • Owned

W. Other Information:
* Protective Services Available:
• Police • Army • Tanod •security guard

* Security Facilities Available:

• Streetlights • Road humps • CCTV • Others:
__________

* Social Facilities Available:

• Courts • Waiting shades • Others: ____________

* Healthcare Facilities Available:

• Botika • Health Center • Others: ____________

* Healthcare Providers Present:

• Nurse • Doctors • Midwives
• Trained Hilot • Albularyo • Others: ____________
DATA BASELINE SURVEY FORM • Age 15 – 19: ___ • Age 20 – 24: ____
• Age 25 – 29: ___ • Age 30 – above: ____
Zone: 7 Household No: • Others, specify: ______
Date of Assessment: March 17, 2022
Name of Assessor: Rica Jane Garcia J. Housing:
• Age of House:
Head of the Family: Evelinda Pgatpatan 0-5 6-10 11-15
* Materials used:
A. Family Size: • Concrete • Wood • Bamboo • Mixed
Number of Adults: 3 Male 2 Female * Number of floors:
Number of Children: Male Female • One • Two • Three • Four
* Lighting Facility:
B. Marital Status: • Electric Bulb • Candles • Gas Lamps
• Single: 2__ Male _1_ Female * General State of Repair:
• Married: 2 • Roof • Floor • Walls • Ladder • Window • Door
• Widow: ___ • Widower: ___ • Foundation • Roof Braces • Rooms • Sink
• Separated: ___ • Kitchen • Toilet • Others: __________________
•
K. Hangouts:
C. Educational Attainment: • Store • Waiting Shade • Court • Yards • House
• Elementary Undergraduate: Male ___ Female •Others: __________________
• Elementary Graduate: __1_ Male __1_ Female
• Highschool Undergraduate: ___ Male _1_ Female L. Animals:
• Highschool Graduate: 2__ Male ___ Female • Dogs: 3 • Cats: __4_ • Pig: _3__ • Chicken: __5_
• College Undergraduate: ___ Male Female • Duck: __5_ • Bird: ___ • Goat: ___ • Carabao: _1__
• College Graduate: ___ Male ___ Female • Cow: _1__ • Others: _________
• TechVoc Course Graduate: ___ Male ___ Female
M. Water (drinking):
D. Occupation: * Source: • Faucet • Deep Well • Pump Well
• Farmer: ___1_ • Carpenter: ____ • Housewife: • Others, specify: Mineral water supply
__1__ • Driver: ____ • OFW: ___2_ * Ownership: • owned• shared
• Others, specify: * Storage: • Refrigerated • Not refrigerated
STUDENT 1 • Covered • Not covered
E. Religion: M. Water (general usage):
• Roman Catholic: __5__ • Baptist: _____ * Source: • Faucet • Deep Well • Pump Well
• Born Again: ____ • Others, specify • Others, specify: ______________
• Drum • Jags • Bottles • Pail • Jar
F. Types of Family: * Storage: • Refrigerated • Not refrigerated
• Dyad • Nuclear • Extended • Covered • Not covered
• Blended • Single Parent • Drum • Jags • Bottles • Pail • Jar
* Usage: • Bathing • Cooking • Laundry
G. Authority:
a. Decision Making: N. Food:
• Patriarchal • Matriarchal • Egalitarian * Cooking facility: • Firewood • Gas stove • Charcoal
b. Child Discipline: • Electric Stove • Others: ________
• Patriarchal • Matriarchal • Egalitarian * Storage: • Refrigerated • Not refrigerated
c. Healthcare Decisions: • Covered • Not covered
• Patriarchal • Matriarchal • Egalitarian * Usual Number of Meals per day: ___3___
d. Financial Management: * Usual Composition:
• Patriarchal • Matriarchal • Egalitarian • Vegetable • Fish • Chicken • Meat • Fruits • Rice
•pork •beef •others

O. Exercise:
• Yes:__ • No: _/____
H. Signs and Symptoms: * Types:
• Head ache: ___ • Colds: __1_ • Cough: ___ • Fever: • Jogging: • Walking: • Work: ___
___ • Others, specify: __________ • Biking: • Stretching: • Others: __________
• Hypertension: ___ • TB: ___ • DM: ___
• Others, specify: __________ __________
• Diagnosed by a practitioner? • Yes: ___ • No: _/__ P. Vices:
• Smoking: _3_____
I. Number of Pregnant Women: • Drinking Alcohol: _2___
AGE <15
Q. Leisure and Recreation: * Level of Satisfaction:
• Chatting: / • Listening to radio: / • Sports: / • Very Satisfied • Satisfied • Not Satisfied
• Sleeping:/ • Walking: / • Watching TV: ___
• Playing cards: ___ • Others: _________________ * Frequency of Visiting Healthcare Facilities:
• Once • Twice • Thrice • As needed
R. Toilet:
* Ownership: • owned • shared * Name of Healthcare Provider/s:
* Type: • Flush • Pail system 1. _______________________________________
• Open pit • Close pit • Water sealed 2. _______________________________________
* Distance: • 2 – 3M • 4 – 5M • 6 – 7M 3. _______________________________________
• 8 – 9M • 9 – 10M • 11 – above
* Reasons for Visiting Health Centers:
S. Garbage: • Health Education • Check – up • Medicine
* Container used: • Trashcan • Plastic • Sack • Feeding Program • Others: _________________
• Box • Pail • Hole
* Method: • Burning • Composting • Open dumping * Name of Organizations:
* Waste Segregation: • Yes • No 1. _______________________________________
2. _______________________________________
T. Drainage System: 3. _______________________________________
* Type of Drainage: • Open • Close
* Household drainage: • Open • Close • None
NOTES:
U. Transportation: DOCUMENTATION :
• Jeepney • Truck • Motorcycle • Tractor
• Tricycle • Van • Other: _____________

V. Income:
* Who earns? • Mother • Father • Both Parents
• Children • All
* Source: • Farming • Self- employment
• Pensions • Others: _____________________
* Monthly income: • 0 – 500 • 501 – 1000
• 1001 – 2000 • 2001 – 3000
• 3001 – 4000 • 4001 – 5000 • 5001 – above
* Expenditure: • Clothing • Education • Food • Farm
• Housing • Medicine • Others: ______________
* Products: • Rice • Corn • Vegetables
• Poultry • Others: Motor parts
* Land ownership: • Tenant • Owned

W. Other Information:
* Protective Services Available:
• Police • Army • Tanod •security guard

* Security Facilities Available:

• Streetlights • Road humps • CCTV • Others:
__________

* Social Facilities Available:

• Courts • Waiting shades • Others: ____________

* Healthcare Facilities Available:

• Botika • Health Center • Others: ____________

* Healthcare Providers Present:

• Nurse • Doctors • Midwives
• Trained Hilot • Albularyo • Others: ____________

* Health Services Offered:

• Immunization • Health Education • Check – ups
• Others: ________________________________