SURVEY QUESTIONNAIRE

I. PERSONAL INFORMATION

NAME OF RESPONDENT: ______________________________ SEX: _________

BIRTHDATE (MM/DD/YYYY): _____________ AGE: ___ NATIONALITY: ____________

EDUCATIONAL ATTAINMENT: __________________ OCCUPATION:

__________________

II. HOUSING/COMMUNITY CHARACTERISTICS

A. IDENTIFICATION OF LOCATION

a. CITY/MUNICIPALITY ____________________________

b. ZONE ____________________________

c. BARANGAY ____________________________

d. PUROK/SITIO ____________________________

e. STREET ____________________________

B. WHAT THREE DEVELOPMENT PROGRAMS DO YOU THINK ARE NEEDED BUT

NOT YET AVAILABLE IN YOU COMMUNITY?

Crop Production Animal/Livestock

Small Fishery Program Health and Nutrition

Handicraft/Cottage Industry Education

Leadership Others (Specify)

III. DEMOGRAPHY

A. HIGHEST EDUCATIONAL ATTAINMENT

GRADE SCHOOL JUNIOR HIGH SCHOOL

SENIOR HIGH SCHOOL COLLEGE

GRADUATE SCHOOL TECHNICAL VOCATIONAL

NAME OF SCHOOL: ___________________________________
COURSE/DEGREE: ___________________________________

B. NATURE OF EMPLOYMENT
PRIVATE EMPLOYEE SELF-EMPLOYED

GOVERNMENT EMPLOYEE BUSINESS OWNER

IV. FAMILY BACKGROUND

D. FAMILY BACKGROUND

Father's Name: ____________________________ Occupation : ____________

Mother's Name: ____________________________ Occupation : ____________

Name of Siblings: Gender: Living with you

1. _______________________________ ____________ ( ) Yes ( ) No
2. _______________________________ ____________ ( ) Yes ( ) No
3. _______________________________ ____________ ( ) Yes ( ) No
4. _______________________________ ____________ ( ) Yes ( ) No
5. _______________________________ ____________ ( ) Yes ( ) No
6. _______________________________ ____________ ( ) Yes ( ) No

C. Income
1. Approximately, how much is your household's total monthly income?

Between P9,100 to P18,200

Between P18,200 to P36,400

Between P36,400 to P63,700

Between P63,700 to P109,200

2. What are your sources of income?

APPROXIMATE
YES (1)
SOURCES OF INCOME AMMOUNT OF
NO (2)
INCOME (IN PESO)
FARMING RICE

POTTED PLANTS

FRUIT TREES

OTHER SPECIFY

During the past 12 months, which of the following program did your
household receive or avail?
( ) Pantawid Pamilya Pilipino Program (4P's)
( ) Philhealth-Employed
( ) Philhealth-Individual payin
( ) Philhealth-Sponsored
( ) Other Health Insurance(MaxiCare, Medicare, Intellicare, etc)
( ) Health Assistance
( ) Education/Scholarships program
( ) Skills or Livehood Training Programs
( ) Other programs, specify:__________________

My signature below confirms that I have done my absolute best to answer

the following question honestly and completely.

______________________________ _________________
SIGNATURE OVER PRINTED NAME DATE