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Community-Based Monitoring System: Household Profile Questionnaire
Community-Based Monitoring System: Household Profile Questionnaire
1 Single house 3 Multi-unit residential (three units 5 Institutional living quarters (e.g. dormitories, lodging houses
2 Duplex or more such as apartment, accessoria, and others)
condominium, etc.) 6 Other housing unit (e.g. boat, cave, trailers,
4 Commercial/ industrial/ agricultural barges, carts, and others)
building/house (e.g. office, factory, or others)
(4) What type of construction materials are the (5) What type of construction materials are the
roofs made of? outer walls made of?
Strong materials (e.g. galvanized iron, aluminum, tile, Strong materials (e.g. aluminum, tile, concrete, brick,
1 1
concrete, brick, stone, asbestos) stone, wood, plywood, asbestos)
2 Light materials (e.g. cogon, nipa, anahaw) 2 Light materials (e.g.bamboo, sawali, cogon, nipa, anahaw)
3 Salvaged/makeshift materials (e.g. tarpaulin, tent) 3 Salvaged/makeshift materials
4 Mixed but predominantly strong materials 4 Mixed but predominantly strong materials
5 Mixed but predominantly light materials 5 Mixed but predominantly light materials
6 Mixed but predominantly salvaged materials 6 Mixed but predominantly salvaged materials
(6) What type of construction materials are the floors made of?
1 Marble 5 Parquet, polished wood
2 Ceramic tiles 6 Palm/Bamboo
3 Cement 7 Wood planks
4 Vinyl, linoleum 8 Natural floor (earth, sand, dung)
(8) How many members are there in the household, including OFWs?
HCN: ______________
C. DEMOGRAPHY
(9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20)
FOR 10
What is YEARS FOR 10 YEARS OLD AND FOR 3 YEARS OLD
Who is the head OLD AND ABOVE AND ABOVE
of the household? __'s In which Was ___’s
ABOVE
relation- nuclear birth regis- What is
Is __ When is What is __'s
N ship to the family tered with What is ethnicity by __'s Where is
male or __'s date Is ___
U head of does the civil ___'s religious ___'s Where was __
Who are the other female? of birth? blood? an
M the ___ registry marital affiliation? country of residing 3 years
B members of the household belong? office? overseas
(civil) destination ago?
E household? ? worker?
status? ?
R
SURNAME 1. Yes 1. Yes
(SEE A (SEE
1. Male MM/ DD/ RELIGIOUS (GO TO (19)) COUNTRY OF 1. Same address now
FIRST NAME CODES G CODES ETHNICITY
AFFILIATION DESTINATION 2. Other address, specify
2. Female YYYY
BELOW) E 2. No BELOW)
MIDDLE NAME 2. No
10
10
F. ECONOMIC ACTIVITY
TO BE ASKED TO ALL MEMBERS INCLUDING OFWs TO BE ASKED TO NON-OFW MEMBERS ONLY
(34) (35) (36) (37) (38) (39) (40) (41) (42)
IF YES IN (34) OR YES IN (35)
FOR 15 YEARS OLD AND
ABOVE
What was ___’s primary occupation
In what kind of industry did __
during the past week?
work during the past week?
Did ___ do any Although __ did
What was __'s
work for at least not work, did __ How many What was __'s total
What is __'s normal working
N 1 hour during have a job or work, jobs or number of hours
nature of hours per day Did __ want more
U the past week? business during businesses worked during the
M employment? during the past hours of work during
the past week? does __ have? (SPECIFY INDUSTRY, E.G. past week?
B (SPECIFY OCCUPATION, E.G. week? the past week?
PRIMARY/ELEMENTARY
E ELEMENTARY TEACHER, RICE
EDUCATION, GROWING PADDY
R FARMER, ETC.)
RICE, ETC.)
10
(43) (44) (45) (46) (47) (48) (49) (50) (51) (52) (53) (54) (55) (56) (57) (58)
FOR 15 YEARS OLD AND ABOVE FOR 5 YEARS OLD AND ABOVE FOR 18 YEARS OLD AND ABOVE IF YES IN (56) IF NO IN (56)
1. Yes
1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes
(SEE (SEE
(SEE CODES GO TO
2. No 2. No (GO TO 2. No CODES CODES 2. No 2. No (A) CASH (B) IN KIND 2. No 2. No 2. No (SEE CODES BELOW) 2. No
BELOW) (51)
BELOW) BELOW)
(49))
10
(44) Class of worker (47) Job search method (49) Reason for not looking for work (58) PhilHealth Membership Type
(50) Last time looked
1 Registered in public employment agency 1 Tired/Believes no work is available for work
1 Working for private household 7 Household, family 1 PhilHealth - OFW
2 Working for private business/establishment/farm 2 Registered in private employment agency 2 Awaiting results of previous job applica 2 PhilHealth - Employed
3 Working for government/government corporation duties 1 Within last month 3 PhilHealth - Individually-paying
4 Self-employed with no paid employee 4 PhilHealth - Sponsored
3 Approached employer directly job application
5 Employer in own family-operated farm or business 8 Schooling 2 One to six months 5 PhilHealth - Lifetime
6 Working with pay on own family operated farm
or business 4 Approached relatives or friends 3 Temporary illness/ disability 6 PhilHealth - Senior Citizen
7 Working without pay on own family-operated farm 9 Others, specify 3 More than six 7 PhilHealth - Indigent
or business 5 Placed or answered 4 Bad weather
months
advertisements 5 Waiting for rehire/
4 Never
6 Searched and applied online
6 Too young/old or retired/permanent
7 Others, specify disability
10
(63) Type of Disability (67) Crime (68) Location of Crime (69) Blood type (70) Rh Factor (71) Nutritional Status
1 Mental/Intellectual 6 Disability due to Chronic illness 1 Theft 1 O 1 Positive 1 Overweight
1 Within the 2 A
2 Hearing Disability 7 Orthopedic (Musculoskeletal) 2 Robbery
3 Psychosocial Disability barangay 3 B 2 Negative 2 Normal
Disability 3 Rape 2 Outside the
4 Visual Disability 8 Multiple Disabilities, specify ____ 4 AB 3 Don’t Know
5 Speech Impairment 9 Learning Disability 4 Physical injury barangay but within 3 Underweight
5 Carnapping municipality/city 5 Don't Know
3 Outside the 4 Severely underweight
6 Cattle rustling
municipality/city but
7 Others, specify within province
4 Outside the
province
6 Rent-free house and lot with consent of owner 26 Sleeping mats (banig )
7 Rent-free house and lot without consent of owner How often is the garbage
(90)
8 Living in a public space with rent 27 Frame without collected?
9 Living in a public space without rent mattress (papag, 1 Daily
folding bed)
2 Thrice a week
ASK (79) IF ANSWER IN (78) IS '1', '3', '4', '5', '6' , '7' OR '9'. IF THE 28 Mattress (kutson ,
3 Twice a week
ANSWER IS '3,' ASK ONLY FOR THE IMPUTED RENT FOR THE HOUSE. sofa bed)
IF THE ANSWER IN (78) IS '2' OR '8,' GO TO (80). 4 Once a week
(79) By your own estimate, how much is the imputed rent per 29 Others, specify ____ 5 Others, specify
month for the house and/or lot?
M. SOURCES OF INCOME
NET INCOME
M.1. ENTREPRENEURIAL ACTIVITIES/SUSTENANCE ACTIVITIES
(A) (B)
During the past 12 months, did you or any member of your household operate in any of the following What was the total net value of income from these activities
entrepreneurial activities? 1 - Yes during the past 12 months? (in pesos)
2 - No
ENTREPRENEURIAL ACTIVITIES/SUSTENANCE ACTIVITIES (A) IN CASH (B) IN KIND
CROP FARMING AND GARDENING such as growing of palay, corn, roots and tubers, 91A 91B
(91)
vegetables, fruits, nuts, orchids, ornamental plants, etc.
LIVESTOCK AND POULTRY RAISING such as raising of carabaos, cattle, hogs, horses, 92A 92B
(92)
chicken, ducks, etc., and the production of fresh milk, eggs, etc.
FISHING such as capturing fish (with a boat of three tons or less); gathering of fry, shells, 93A 93B
(93)
seaweeds, etc.; and culturing fish, oysters, mussel, etc.
FORESTRY AND HUNTING such as tree planting (ipil-ipil), firewood gathering, small- 94A 94B
(94) scale logging (excluding concessionnaires), charcoal making, forestry product gathering
(cogon, nipa, rattan, bamboo, resin, gum, etc.) or wild animals/birds hunting
95A 95B
(95) WHOLESALE AND RETAIL including market vending, sidewalk vending, and peddling
MANUFACTURING such as mat weaving, tailoring, dressmaking, bagoong making, fish 96A 96B
(96)
drying, etc.
COMMUNITY, SOCIAL, RECREATIONAL, AND PERSONAL SERVICES such as medical 97A 97B
(97)
and dental practice, practice of trade, operation of schools, restaurants and hotels, etc.
MINING AND QUARRYING such as mineral extraction like salt making, gold mining, 99A 99B
(99)
gravel, sand and stone quarrying, etc.
(100) CONSTRUCTION like repair of a house, building, or any structure 100A 100B
(101)
ACTIVITIES NOT ELSEWHERE CLASSIFIED including electricity, gas and water; 101A 101B
financial, insurance, real estate, and business services
(102A): Add the net income (102B): Add the net income
from (91A) to (101A) from (91B) to (101B)
(102) TOTAL NET INCOME FROM ENTREPRENEURIAL ACTIVITIES
102A 102B
M.2 SALARIES AND WAGES FROM EMPLOYED MEMBERS
(103A): Add all salaries/wages (103B): Add all salaries/wages
(103) TOTAL SALARIES AND WAGES of all members in cash in of all members in kind in
Question (53)A Question (53)B
103A 103B
M.3. OTHER SOURCES OF INCOME
GROSS INCOME
During the past 12 months, how much did you or any member of your household receive from the following?
(A) IN CASH (B) IN KIND
(105) Cash receipts, gifts, support, relief, and other forms of assistance from abroad
105A 105B
(106) Cash receipts, support, assistance, and relief from domestic sources
106A 106B
(107) Pension and retirement, workmen's compensation, and social security benefits
107A 107B
(108)
Net share of crops, fruits, and vegetables produced, aquaculture products harvested or livestock and 108A 108B
poultry raised by other households
(109) Rentals received from non-agricultural lands, buildings, spaces, and other properties
109A 109B
(110) Interest from bank deposits, interest from loans extended to other families.
110A 110B
During the past 12 months, 3 Boat without engine but with outrigger
During the past 12 months, what temporary and
how much did you harvest? 4 Boat without engine and outrigger
permanent crops did your household harvest?
(in kilograms) 5 Raft
1 (129) (130)
2 What kind of gears/accessories/devices How many does the household
was/were used? own?
3
4 KIND Number
5 1
(121) (122) 2
How many of each of the folllowing How many agricultural 3
agricultural equipment/facilities does equipment/facilities does the
the household use? Number household own? 4
(139) RReason for changing crop (166) How long did you stay in the evacuation area? (in days)
1. The inputs to the former crop are more expensive (163) Primary reason for moving out/ leaving permanently
2. The present crop is more resistant to pests and diseases 1. Typhoon 5. Volcanic eruption 8. Fire 11. Infrastructure
3. The present crop does not require much water 2. Flood 6. Landslide or 9. Forest fire development project
4. The present crop enables the member to earn more profit 3. Drought mudslide 10. Armed conflict 12. Others, specify
5. The seedling of the former crop is no longer available 4. Earthquake 7. Tsunami
6. Others, specify (165) Evacuation areas
(141), (146), (151) 1. School 4. Relative's house 6. Barangay/City hall 9. Others, specify
1 - Philippine Crop Insurance Corporation 3 - Bank 2. Church 5. Neighbor or 7. Multi-purpose hall
2 - Private insurance company 4 - Others, specify 3. Covered court/gym friend's house 8. Designated evacuation centers
T. PROGRAMS
(182) IF YES IN ((182))
During the past 12 months, did you or any member of -(181) -(180) -(179) -(178)
your household receive or avail of any of the following
programs? What is/are the name/s of the
How many Who
What is the name of the member of the household who
household implemented this
program? is/are beneficiary/ies/ members
member/s are program?
of the program?
covered by or
members of this
1 - Yes program? NAME OF HOUSEHOLD (SEE CODES
TYPE OF PROGRAM FULL NAME OF PROGRAM BELOW)
2 - No MEMBER/S
8. Community-Based Employment
Program (CBEP)
1.
10. Health assistance
2.
1.
11. Supplemental feeding
2.
1.
12. Education/scholarship program
2.
1.
13. Skills or livelihood training program
2.
1.
14. Credit program
2.
1.
15. Housing program
2.
1.
3.
(-178) Program Implementer 1 - National 5 - Congress/District
2 - Province 6 - Private Organizations/NGOs
3 - City/Municipality 7 - Don't know
4 - Barangay 8 - Others, specify