Form 1 Tacloban RUP Baseline Survey Questionnaire Part 1.

Demographic Profile: Name of Barangay (Ngaran han Brgy) : Name of Respondent (Ngaran han ginpapaki-anhan) : Age( edad )
Trabaho Monthly Income (binulan nga kita):

No. Enumerator (an nag-interview) Date Interviewed ( petsa )
Civil Status (estado)

Gender

Male

No. of Children (pira an anak) Elem HS Coll Post Gr None Course: _______________________________________________

(kasarian) Female

Educational Attainment

1. Policy Domain : Physical Environment and Infrastructure (PD1.1) Do you have safe and potable water source? (may ada ba kamo surok han malimpyo nga tubig?) Yes No If yes, what is the source? Ano an surok? Tacloban Water District Deep well Others specify: ________________ (PD1.2) Do you have toilet facility? (may ada ba kamo kalugaringon nga toilet?) (PD1.3) Is there regular garbage truck collector in the area? (may ada ba napakanhi nga mga paragbasura ?) (PD1.4) What do you use for cooking ? (ano an gin gagamit niyo ha pagluto?) (PD1.5) Yes No Yes No LPG Wood Charcoal Paper Yes No If yes: How often? Daily Monthly Other specify: ____________ Weekly

Is there any member of the family who met any road accident in the past 6 months? (may ada ba meyembro han pamilya nga na aksidente ha kadalanan ha nakalabay nga 6 ka bulan?) if yes, how serious? died (namatay) hopitalized (nahospital) bruises (galos la)

2. Policy Domain : Social and Human Development (PD2.1) Do you have children at the age of 25 below? Yes No (may ada ba kamo anak nga na-edad 25 paubos?) If yes, how many are attending school? At what level? ( kun oo, Pira an naeskwela? Ano nga level?) Yes No Level: Primary Secondary Post grad (PD2.2) (PD2.3) Other

College

College

Specify:____________________

How many of your children completed elementary level? _______________________ (Piraha imo mga anak an nakatapos han elementarya?) Is your family enrolled in PhilHEALTH? (An iyo ba pamilya may-ada PhilHEALTH insurance? ) If yes, how?(kun oo, paano ka nagkamayda Philhealth?) Personal CSWDO Province Others Specify: ____________ Yes No Yes No

(PD2.4)

Do you have a Child under five years old? (May-ada kaba anak nga 5 ka tuig ngan ubos? if yes, indicate number 0-1year
> 1 year old,but <5 yrs. Old

(PD2.4.1) Is the child Fully Immunized (FIC)? Yes No Unsure (Kompleto ba han bakuna han imo anak?) If no, indicate needed vaccine ____________________________________________ (see immunization card, when available) (PD2.4.2) Where was the child immunized? (diin ba an imo anak na bakunahan?) Gov't facility (RHU, BHS, Hosp) Private clinic/ hosp

(PD2.4.3) Do you think it is necessary to submit your child for immunization? (Ha pagkita mo, kinahanglan ba nga bakunahan an imo anak?) Yes No If yes, Why?________________________________________________________________ (PD2.4.4) Who encourage you to submit your children for immunization? (Hin-o an nagaghat ha imo nga pabakunahan an imo anak?) RHU (PD2.6) (PD2.7) Neighboor Friends Relatives Other Specify: _____________________

Have you practiced breastfeeding in all your children until 6 months? Gin pasusu ba an iyo mga anak ha nanay ha sulod han 6 ka bulan? Yes No If no, Why?________________________________________________________________ Is there any member of the family who got pregnant at the age below 18? May ada ba burod nga meyembro han pamilya nga ada ha

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Tacloban RUP baseline questionnaire City Health Office

___________________________________________________________ Kon oo. kakan-o ka nanganak? (PNC2) Where did you last delliver your baby? Diin ka nanganak? Gov't facility (RHU. hin-o an nagpa-anak? Midwife TBA Where do you prefer to deliver? Diin mo gusto manganak? Gov't facility (RHU.7a (ANC1) (ANC2) No ANTENATAL CARE (for WRA only. Hosp) Private clinic/ hosp At home (PNC3) if at home. where and Why?________________________________________________________________ 5.edad nga 18 o ubos pa? Yes PD2. Impotante ba ha mga burod nga magpa-prenatal check-up?) Are all the children you have were delivered at the Hospital or centers? An ngatanan ba nga imo mga anak ha hospital o sentro gin anak? Yes No If no. BHS. POSTNATAL CARE (for WRA only) Have you been pregnant or ever given birth? Nagburod kna ba o nanganak na? (PNC1) Yes No if yes. both did not plan the pregnancy (Kun diri. were you given dose of Tetanus Toxoid? (han pagpa-check up mo. 15-48 years old) Are you pregnant now? (Burod kaba yana?) Yes No Not sure No Wife/Husband only did both of you plan this pregnancy ? Yes Kamo ba ngan imo asawa an nagplano han imo pagburod?) If no.b.8) Gov't facility (RHU. hin-o an naruyag ga magburod ka?) (ANC3) (ANC4) (ANC5) (ANC6) Age of present pregnancy (in weeks) Pira na ka semana? Did you have prenatal check up? (Nagpapa-prenatal check-up kaba?) How many prenatal check ? (pira na ka beses?) 1st Yes weeks No (if no go to ANC9 ) if no why? _____________________________________ 2nd Yes 3rd No During prenatal check up. Hosp) MD Nurse (PNC4) Private clinic/ hosp At home (PNC5) (PNC6) (PNC7) (PNC8) Pls specify reason: __________________________________________________________________________________________ Have you / your wife ever deliver an alive baby but later died? Namatyan na ba kamo hin baby? Yes Who handle the delivery? Hin-o an nagpa-anak? Midwife TBA MD Yes Yes No Nurse No No Have you ever had post partum check up? Nagkamayda ba kamo check-up katapos panganak? Would you encourage mother to have post partum check up? (mag-agda ba kamo ha iba nga magpa-check-up katapos manganak?) Please check your level of knowledge or understanding about the following topics (alayon pag tsek subay han imo na hihibaruan hiunong hini nga mga topiko) Normal Delivery very High High Low (Normal nga panganak) Birth delivery w/ complication (Panganak nga may komplikasyon) Pre and Post natal Check up very High very High High High Low Low no comment no comment no comment Page 2 Tacloban RUP baseline questionnaire City Health Office . BHS. Hosp) Private clinic/ hosp Age Yes No Do you think it is important that every pregnant should have prenatal check up? (ha pagkita mo. gin tagan kaba Tetanus Toxoid?) How many doses of Tetanus Toxoid did you/ she received? (pira ka beses?) Where did you have your prenatal Check up? (diin ka nagpa-check up?) Any other pregnant in the family? (pls specify) (May ada ba iba nga burod dinhi ha iyo pamilya?) 1st (ANC7) 2nd 3rd (ANC8) (ANC9) (ANC10) (PD2. please specify your last delivery date. BHS. who handle the delivery? Kon ha balay.

000-11. BHS. nagpa-examin kaba han imo lako ha sentro?) Did you know the result? (Maaram kaba han resulta?) Where do you prefer to have consultation (diin mo mas karuyag magpa-konsulta?) Gov't facility (RHU. etc) Do you believe that TB cannot be cured? (Natoo ka nga an TB diri nabubulong?) TB can be diagnosed only through X.DOTS? Nakabati naba kamo han TB-DOTS? Are currently taking medication against TB? May ada kaba gin tutumar nga bulong ha pagka yana? Source of Medicines (tikang diin an imo bulong/medesina) Pvt. etc.1) (TB9) (TB10) (TB11) Why? Kay-ano? Have you heard about TB .000 below 5. pira iya edad? TB knowledge (TB1) (TB2) (TB3) (TB4) Do you know that one can get TB by sharing eating utensils Yes (Maaram kaba nga nakaka tapun TB an paggamit hin pareho nga plato. senior citizen group. Hosp) (TB5) (TB6) (TB7) (TB8) Yes Yes Yes No No No Private clinic/ hosp why? Yes Yes RHU Yes Yes No No (if No.000 above Any member of the family involved in any social groups? Yes No (May ada ba nga iyo myembro hin usa nga organisasyon? Example Kooperatiba.100-5. ano nga grupo? PO Senior citizen Coop PTCA credit group _______________________________ other Page 3 Tacloban RUP baseline questionnaire City Health Office . how old is he/she? Kun oo. was it given free? Kon tikang ha RHU.000 12. was your sputum examined at the health Center? (kun oo. Do you have treatment partner? Kun oo.2) What is the status of your house? (Ano an estado han iyo balay?) 4.1) (PD3.3) What are the sources of family income? (Ano an surok han kita han pamilya?) How much is your monthly income? (Pira an kita ha usa ka bulan?) (PD3. Policy Domain : Economics (PD3. baso.10 Is there any member of the family who smoke? (may-ada ba myembro han pamilya nga nasigarilyo? 10-13 If yes.2) employed 1.100-3.000 relatives specify______________________ 3.000-8. religious group. what organization ? kon oo. Policy Domain : Governance (PD4. go to PD3.(pagpa-check-up san-o ngan katapos panganak) family Planning Methods (pagplano han pamilya) very High High High Yes 14-16 17-19 Low Low No 20 above no comment no comment Contraceptive use very High (mga pamaagi han family plananing nga gin gamit) PD2. Clinic/ hosp No No (TB12) If the source RHU.000 9.) If yes.ray (An TB masasabtan la pinaagi han xray) Yes Yes No No Yes No Not sure Not Sure Not sure No Do you have any relative or member of the family who has TB? (May ada ba myembro ha pamilya nga mayda TB?) Do you have any cough lasting a month or more? (may-ada kabs ubo nga subra usa ka bulan?) if yes.000 owned rented business other 1. libre ba nga ginhatag? If yes. mayda kaba kabulig han imo pagtambal 3.

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