ACTION PLAN FOR COMMUNITY IMMERSION

Objectives
Activities
Time Frame
Persons Involved
Expected Outcome

Prepared by:

_________________________
Name of Student

Questionnaire
Higher Education Institution
National Service Training Program
Literacy Training Service

COMMUNITY ASSESSMENT PROGRAM

Family Socio Economic Profile

Barangay: Brgy.Tamia, Compostela Davao de Oro Date: May 25, 2020

Place: Project-8, Barangay Tamia NSTP Student: Crislie L.Remis_

*Fill-in the information accurately.

A. Profile of the Respondents:

Father
Name: Romel Rabe Remis Age: 50 years old
Gender: Male ____________________ Marital Status: Married___
Highest Educational Attainment: Second Year High School_________________
Religious Affiliation: Roman Catholic Occupation: Farmer
Monthly Income: 4,000 per month____________ Job Status: __None_____
Permanent: ___✓_
Contractual: ___________________
Mother
Name: Rowena Lamo-Remis Age: 47 years old
Gender: Female Marital Status: Married
Highest Educational Attainment: Third Year College
Religious Affiliation: Roman Catholic Occupation: Banana Packer
Monthly Income: 4,500per month Job Status: Packer
Permanent: __
Contractual: ✓
B. Members of the Family
Name Gender Civil Status Highest Still Occupation Job Monthly
Educational studying status Income
Attainment (state what
Particular
course and
year )

Ctistian Mel L. Remis Male Single Grade 2 (ongoing) Student

Crisly Jane L. Remis Femal

3.

4.

5.

C. Extended Family
Please check:
 Mother
 Father
 Brother
 Sister

D. Expenditures
How much is your family monthly expenses on the following?
a. Food ___________________________
b. Education of Children __________________________
c. Water __________________________
d. Fare in going to work ___________________________
e. Electricity _______________________
f. Fare of the student ______________________________
g.House rental____________________
h. Total Expenses_________________________________
(if renting)

E. Health
1. Do you have members in the family suffering from any ailment?

High blood (Who?) _________________ Heart Disease (Who?) __________

Diabetes (Who?) ___________________ Pneumonia (Who?) ____________
Bronchitis (Who) ____________________ etc. (Please specify) ____________

2. Do you practice family planning? Yes ___ No __ Since When? _____________

3. Where do you consult when the members of the family get sick?
Faith Healer ________________ Public Health Center ___________________
Quack Doctor _______________ Private Clinic/Hospital __________________

F. Water Sanitation
1. Source of Water:

Please Check:
 MWSS ð Well
 Artesian Well ð River

2. Do you have a comfort room? What type?

 Flush typeð No Flush
 Thrown in the waterð Others (Please specify)

G. Other Inquiries
1. Have you experienced any domestic violence in the family?
ð Yes ð No
2. How many members in the family who are already voters? (Please specify)

3. Were you able to vote during election?

ð Yes ð No

4. What are the present problems you are encountering in your community? (Please
specify)
*Identify one learner (it could be your younger sibling/cousin) and fill in the information
properly.

LEARNER’S PROFILE

Full Name (Surname First) –

Address -
Age -
Birthday -
Place of Birth -
Contact Number -
______________________________________________________________________
___________________________

Name of Parents -
Occupation -
Place of Work -
Order of Siblings -

______________________________________________________________________
___________________________

School Last Attended -

Academic Year -
Previous Final Average -
Things like to do most -
______________________________________________________________________
___________________________

Lessons want to learn more –

Style of teaching (group or individual) –
Reasons for not going to school –
Future Plans -
______________________________________________________________________
___________________________

Rank the following according to their mastery:

_____ Writing
_____ Reading
_____ Numbers
_____ Cultural Arts (singing, dancing, drawing)