B.

Home and Environment

Date Assessed: _________________________
1. Home
a. Ownership:
( ) owned ( ) rented ( ) rent- free
b. Construction materials used: ( ) Light
( ) Mixed
( ) Strong
c. Number of rooms used for sleeping: _____________
d. Lighting facilities:
( ) Electricity
( ) Kerosene
( ) Others:
Specify;______________
e. General Sanitary Conditions:
________________________________________________________________________________
________________________________________________________________________________
__________________________________________________________________________
2. Drinking Water Supply
Source: ( ) private ( ) public
Distance from the house: ____________________________________
Storage:
( ) none (direct from faucet or pipe)
( ) large covered container with faucet
( ) large uncovered container without faucet
( ) others, specify__________________
3. Kitchen
Cooking facility: ( ) electric stove
( ) gas stove
firewood/ charcoal
Sanitary Condition: pots and pans________________
Presence of insects ___________
Utensils_____________________
Drainage facilty: ( ) open drainage
( )blind drainage

( )

( ) none

4. Waste Disposal
a. Refuse and garbage
Container: ( ) covered ( )open
( )none
Method of disposal
( ) hog feeding
( ) open burning
( ) open dumping ( ) garbage collection
( ) burial in pit
( ) others, specify
( ) composting
____________________
b. Toilet
Type: ( ) none
( ) pail system
( ) overhung latrine
( ) Antipolo
( ) open pit privy ( ) water-sealed latrine
( ) closed pit privy ( ) flush type
( ) bored-hole latrine
( ) others, specify
Distance from House: _______________________________
Sanitary Condition: ________________________________
5. Domestic Animals
KIND

NUMBER

WHERE KEPT