HOUSEHOLD INTERVIEW SURVEY

Traffic and Transport Management for Philippine CDS Cities Project

Form 1. Household Information
Control No. (1) Household Head
Certification

I hereby certify that the data Family Name

contained herein were obtained/
reviewed in accordance with the (2) Address
given instructions.

No. Street
____________________
(3) Type of Dwelling (pls. write an 'X' mark in one of the boxes)
Enumerator
(Signature over printed name)
Purely Residential Purely Commercial
____________________
(4) Type of House/ Establishment (pls. write an 'X' mark in one of the boxes)
Date Accomplished

Single detached Single wall to wall

____________________
Supervisor Up and down w/ More than 2 floors
(Signature over printed name) roofdeck
(5) Construction Materials of the Roof (6) Construction Materials of the Outer
(pls. write an 'X' mark in one of the boxes) (pls. write an 'X' mark in one of the boxes)

Galvanized iron/aluminum Cogon/nipa/anahaw

Tile concrete/clay tile Asbestos

Half galvanzied iron and Makeshift/salvaged/improvised

half concrete materials
Wood Others, speciify______________

(7) Tenure Status of the House/ Establishment and Lot

(pls.Owned
write an 'X' mark in one of the boxes) Rent-free with consent of the owner
Rented Rent-free without the consent of the owner

Mortgaged Others, specify_____________________

Under 4 years old 4 years old and above

w/o disability w/ disability w/o disability w/ disability
(8) How many people reside in your household?
Male
Female
Total

Number of Units
Pedicab Motorcycle Tricycle
(9) How v
many vehicles are owned or rented by household members?
Owned
Not owned
Bicycle Jeepney Taxi FX Taxi Car/Jeep Utility Veh

under 1,500 1,500-2,499 2,500-4,999 5,000-7,499 7,500-9,999

(10) What is the Monthly Household Income of the Household Head? (pls. write an 'X' mark in one of the boxes)

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 HOUSEHOLD INTERVIEW SURVEY
Traffic and Transport Management for Philippine CDS Cities Project
Form 1. Household Information
Control No. (1) Household Head
Certification

Page 1 of 2
es Project

First Name

Barangay

rely Commercial Residential w/ Business

Activity
of the boxes)

le wall to wall Apartment/single/duplex/

up and down
e than 2 floors Condo Unit (Makati Homes)

on Materials of the Outer Walls

n 'X' mark in one of the boxes)

Concrete/brick/stone
Wood
Half concrete/brick/stone and half wood
Galvanized iron/aluminum
Bamboo/sawali/cogon/nipa

Asbestos
Glass

Makeshift/salvaged/improvised materials
Others, specify________________

No walls

Utility Veh

10,000-14,999 15,000 and above

Page 1 of 2
es Project

Page 1 of 2
Form 2. Household Member Information (to be filled up for all members aged 4 and above)
Member 1 Member 2 Member 3 Member 4 Member 5
(1) Age

(2) Gender

(3) Relation to Heada

(4) Disabilityb
(5) Work Address
No./Street

Barangay

(6) School Address

No./ Street

Barangay

(7) Occupationc

(8) Employment Sectord

(9) Highest Educ. Attaintmente

(10) Monthly Incomef

a
Relation to Head: b
Disability: c
Occupation: d
Employment Sector: e
Highest Education Attainment:
1 - Head 1 - No 1 - Officials of Gov't & Special 1 - Agriculture, Hunting & Forestry 1 - No grade completed
2 - Spouse 2 - Yes Interest Org., Corporate 2 - Fishing 2 - Elementary level
3 - Son Exec., Managers, Managing 3 - Mining & Quarrying 3 - Elementary graduate
4 - Daughter Proprietors & Supervisors 4 - Manufacturing 4 - High school level
5 - Stepson 2 - Professionals 5 - Electricity, Gas & Water Supply 5 - High school graduate or higher
6 - Stepdaughter 3 - Technicians & Assoc. 6 - Construction
7 - Son-in-law Professionals 7 - Wholesale & Retail Trade;
8 - Daughter-in-law 4 - Clerical Worker Repair of Motor Veh.,
9 - Grandson 5 - Service Workers & Shop & Motorcycles, Personal &
10 - Grandduaghter Market Workers Household Goods
11 - Father 6 - Farmers, Foresty Workers & 8 - Hotels & Restaurants
12 - Mother Fishermen 9 - Transport, Storage & Comm.
13 - Brother 7 - Trades & Related Workers 10 - Financial Intermediation
14 - Sister 8 - Plant & Machine Operators & 11 - Real Estate, Renting &
15 - Uncle Assemblers Business Activities
16 - Aunt 9 - Laborers & Unskilled Workers 12 - Public Adm. & Defense;
17 - Nephew 10 - Student (Elem.) Compulsory Social Security
18 - Niece 11 - Student (H.S. & Univ.) 13 - Education
19 - Other Relative 12 - Housewife 14 - Helath & Social Work
20 - Non-Relative 13 - Jobless 15 - Other Community, Social &
21 - Boarder 14 - Others, specify____________ Personal Service
22 - Domestic Helper 16 - Private Households
17 - Extra-territorial Organizations

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14 - Helath & Social Work
15 - Other Community, Social &
Personal Service
16 - Private Households
17 - Extra-territorial Organizations

Page 2 of 2
 Member 6 Member 7

Monthly Income:
f

1 - Under 1,500
2 - 1,500 to 2,499
3 - 2,500 to 4,999
4 - 5,000 to 7,499
5 - 7,500 to 9,999
6 - 10,000 to 14,999
7 - 15,000 and above

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Page 2 of 2
Form 3. Household Member Trip Information (to be filled up for all members aged 4 and above)
Member 1 Member 2 Member 3 Member 4 Member 5
1st TRIP
Type Brgy Type Brgy Type Brgy Type Brgy Type Brgy Type
(1) Origin
(2) Time Started : : : : :
(3) Time of Arrival : : : : :
Type Brgy Brgy Type Brgy Type Brgy Type Brgy
(4) Destination Type Type

(5) Trip Purpose

(6) Mode of Travel
2nd TRIP
Type Brgy Type Brgy Type Brgy Type Brgy Type Brgy Type
(1) Origin
(2) Time Started : : : : :
(3) Time of Arrival : : : : :
Type Brgy Type Brgy Type Brgy Type Brgy Type Brgy Type
(4) Destination
(5) Trip Purpose
(6) Mode of Travel
3rd TRIP
Type Brgy Type Brgy Type Brgy Type Brgy Type Brgy Type
(1) Origin
(2) Time Started : : : : :
(3) Time of Arrival : : : : :
Type Brgy Type Zone Type Zone Type Zone Type Zone Type
(4) Destination
(5) Trip Purpose
(6) Mode of Travel
4th TRIP
Type Brgy Type Brgy Type Brgy Type Brgy Type Brgy Type
(1) Origin
(2) Time Started : : : : :
(3) Time of Arrival : : : : :
Type Brgy Type Brgy Type Brgy Type Brgy Type
Type Brgy
(4) Destination
(5) Trip Purpose
(6) Mode of Travel
Note: Add more sheets if there are additional trips.

Origin and Destination: Trip Purpose: Mode of Travel:

1 - Residence (Home) 1 - To Home 1 - Walking
2 - Commercial/Financial Institution 2 - To Work 2 - Bicycle
3 - Factory/ Warehouses 3 - To School 3 - Motorcycle
4 - School/University 4 - To Shop 4 - Tricycle
5 - Recreational Place/Park 5 - Leisure/ Social 5 - Car/Jeep/Utility Vehicle
6 - Retail Shop 6 - Others 6 - Taxi
7 - Government agencies/ offices 7 - Boat
8 - Public health facilities 8 - Others
9 - Private health facilities
10-Others
5 - Recreational Place/Park 5 - Car/Jeep/Utility Vehicle
6 - Retail Shop 6 - Taxi
7 - Government agencies/ offices 7 - Boat
8 - Public health facilities 8 - Others
9 - Private health facilities
10-Others
Member 6 Member 7

Brgy Type Brgy

: :
: :
Brgy Type Brgy

Brgy Type Brgy

: :
: :
Brgy Type Brgy

Brgy Type Brgy

: :
: :
Zone Type Zone

Brgy Type Brgy

: :
: :
Brgy Type Brgy