HOUSEHOLD SURVEY FORM

INSTRUCTION: Please provide the answers to the questions below. No questions must be left unanswered. For question/s which
is/are not applicable, kindly write N/A.

I. FAMILY MEMBERS AND CHARACTERISTICS

A. Basic Information About HEAD OF THE FAMILY

Name: Bless Batuyog Birthdate: December 16 Age: 20 Sex: Female

Highest Educational Attainment: High School Occupation: Student Monthly Income: 10,000P

Civil Status:

 Married □ Legally □ Common Law

 Widowed
 Separated
 Single

Employment Status:

 Permanent □ Private □ Public

 Temporary □ Casual□ Contractual
 Self-employed
 Unemployed

B. Other Family Members:

No. of children in the household:
Total: 0 Male: 0_____ Female: 0_____
No. of other dependents in the household:
Total: 0_______ Male: 0_____ Female: 0_____

RELATION HIGHEST
TO HEAD AG CIVIL EDUCATIONA OCCUPATIO MONTHL
NAME SEX
OF THE E STATUS L N Y INCOME
FAMILY ATTAINMENT
N/A

**NOTE:
 For children ages 3-5, indicate under educational attainment column whether attending daycare or not.
 For children ages 6-16, state whether currently studying or not under occupation.

II. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

A. Religion: (please specify) Born Again Christian________________________
B. Primary dialect/ language spoken at home: Ilucano_________________________
C. Income:
C.1 Estimated average family income per month (total family income: from A and B, please check)
Above 50,000______ P30,001-35,000 _____ P10,000-15,000 X____
P45,001–50,000 ____ P25,001-30,000 _____ P5,001-10,000 ____
P40,001-45,000 ____ P20,001-25,000_____ P1,001-5,000 _____
P35,001-40,000_____ P15,001-20,000_____ P1,000 & below____

C.2 Primary source of Livelihood:

Farming _____ Owned: ____ Tenanted: ____
Laborer: _____ Carpentry: _____
Fishing: ______ Peddling: _____
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 Government Employee: ______
Small Industries: (sari sari store, carenderia, etc. )_____
Others (specify): Allowance____

C.3 Food Production Engaged in (may check more than one): _____ yes, _X___no
(if yes, please answer below)

RESOURCES FAMILY SELLING BOTH

CONSUMPTION
Vegetable gardening
Piggery
Poultry
Fruit trees
Others: (pleases specify)
__________________

__________________

D. Real Property
D.1 Type of property owned:
___ Farmland (rice, coconut, others)
___ Residential Lot
___ Residential lot with house
___ Commercial Lot with building
_N/A__ Others (Specify)
D.2 Housing:
a. ownership: ___ owned ____ rented _X__ shared
b. type of construction:
___ light
_X__ medium (wooden floors/walls with nipa roof)
___ heavy (dominantly concrete/ hardwood with galvanized sheets)
D.3 Facilities:
a. Type of appliances owned:
___ radio ___ CD _X__ Electric Fan
___ cassette ___ DVD _X__ refrigerator
___ TV __X_ Gas burner ___ Computer Set
_X__ Laptop ___ Others: (specify) _____________________

b. Vehicles owned: (for people and/or goods)

___ car ___ tricycle _N/A__ others (specify)
___ private jeep ___ motorcycle _____________________
___ truck ___ kuliglig _____________________

c. Utilities
__X_ Electrical connection

__X_ Telephone / cellphone

D.4 All family members with basic clothing of at least 3 sets of external and internal clothing:
__X_ yes ___ no

D.5 Family Consumption:

Family Food Consumption Adequate (please check) Inadequate (please check)

Eat 4 times or more
Eat 3 times a day X
Eat twice a day
Eat once a day

E. Decision making pattern (please check the appropriate column, you may check more than one)

DECISION AREA FATHE MOTHE CHILDRE SINGLE

R R N
Family Expenses N/A
Health X
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 Education X
Participation in Community activities X

III. HEALTH STATUS AND PRACTICES

A. Food, nutrition and Immunization Status (children 0-72 months old)

a.1 Infants exclusively breastfed for four months:

Name of Child Exclusively breastfed for 6 months If NO, state reason

N/A YES NO

a.2 Supplementary feeding: (children 0-72 months old)

Name of child Supplementary feeding If yes, what were the types of food given? Age started
N/A Yes No

a.3.1 Nutritional Status of children 0-72 months

Name Birthdate Date of Weight Status Height Status

Weighing
N/A

a.3.2 Immunization Status (Children 0-12 months old)

Name Age in Types of Immunization

months BCG OPV1 OPV2 OPV3 PCV1 PCV2 PCV3 IP MM Penta MM Status
V R R

N/A

B. Prenatal, Natal and Postnatal Care (to be answered if there were pregnant/lactating mothers and deliveries in
the past year)
1. Pregnant and lactating mothers provided with Iron and Iodine supplementation:
____ yes ___ no
2. Pregnant mothers given at least 2 doses of Tetanus toxoid:
___ yes ___ no
3. Pregnant mother given prenatal care: ___ yes ___ no
3.1 First visit made in the first trimester ___ yes ___ no
3.2 Had at least 1 visit per trimester ___ yes ___ no
3.3 Total number of pre-natal visit: ____

4. Postnatal visit within 4-6 weeks postpartum: ____ yes ___ no

5. Delivery handled by trained health personnel: ___ yes ___ no
If yes, specify: ___ trained hilot
___ RHM
___ Nurse
___ Physician
If no, who handled the delivery? (specify) _______________________
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 C. Family Planning (To be answered by MCRA’s in the household):
1. Couples with access to family planning services: ___ yes ___ no
2. Couples practicing family planning: ___ yes ____ no
If yes, specify method: ________________________
If no, state reason: ____________________________

D. Morbidity (Past 1 year, please counter-check with secondary data)

1. Any of the children below 6 years old had more than 1 diarrheal episodes: ____ yes ___ no
2. Other illnesses experienced by family members:

Type of Illness Age Sex Health worker attended Treatment used

N/A

E. Mortality (Past 1 year, please counter-check with secondary data)

1. With deaths in the family due to preventable diseases (past 1 year): ____ yes ____ no
2. Causes:

Type of Illness Age Sex Health worker attended Treatment used

N/A

F. Health Seeking behavior and Utilization of Health Services:

1. Family member with Phil health:

Name Status Remarks

Bless Covered

2. Family members avail of health services: __X_ yes ___ no

3. With solo parent availing health services: ___ yes ___ no
4. Delays in accessing health care
a. Reasons in delaying decisions to seek health care:
___ Failure to recognize danger signs
___ lack of money to pay expenses
___ No available person to take care of the children and home
___ Lack of companion in going to the health facility
___ others; specify _________________________
b. Reasons for reaching appropriate care in a health facility
__X_ Distance of home to a health facility
___ Lack of transportation
___ others: specify _____________________________
c. Delays in Receiving appropriate care in a facility
___ Shortages of supplied and basic supplement in a health facility
___ lack of skilled health personnel in the hospital
___ Poor skills of health care providers
___ Others: specify ________________________________
5. Health services most frequently availed of: (please rank)
__4_ RHU _5__ Private Clinic
_3__ BHS __2_ Hospital _6__ private _1__ public
6. Health worker preferences during illness (rank using numbers according to who is seen first)
__1_ Medicine man __2_ Nurse others: specify ________________
__4_ Midwife __3_ Doctor
7. Health interventions done during illness (Rank using numbers according to who is seen first):
__1_ Self-Medication: Specify ________Advil____________
__2_ Consult medicine man (Albularyo)
__4_ Consult RHM
__3_ Consult Nurse
___ Bring Patient immediately to the hospital
___ Others: specify ________________________

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IV. ENVIRONMENTAL CONDITION
a. Safe water
1. Access to safe drinking water within 250 meters or 10 minutes’ walk from their home:
_X__ yes ___ no
2. Water source (please check):
Level 1: ____ Protected well
____ Developed spring
Level 2: ____ Piped distribution network and communal faucet
Level 3: __X__ Waterworks system for individual households
Others: ____ Shallow dug well
____ Unprotected spring
____ Others: (Specify) ______________________________
3. Method of water storage: ____ open container __X__ covered container
4. Method of water treatment: __X__ chlorination ____ boiling ____ no treatment

b. Method of Excreta Disposal:

Types: __X__ WST owned:

X___ functional ____ non-functional

____ WST shared:
___ functional ____ non-functional
____ without, specify: _________________________________

c. Method of Domestic Water waste Disposal: __X_ Blind drainage ___ Open Drainage

d. Method of Garbage collection and disposal (common HH practices):

Collection: ___X_ open receptacle ___ none
____ covered receptacle

Disposal: ____ composting ____ burying

____ burning ___X_ open dumping
____ riverside dumping ____ others

e. Method of animal management:

Kind of animals: specify: ______Cat_______ _X__domestic _____
agricultural
_____ tied ____ fenced ____ astray
_____ both ____ no animals
f. Food Storage:
__X__ cabinet ___ covered plates ___ others: specify
__X__ covered basket _X__ refrigerator ____________________

V. PEOPLES PARTICIPATION IN COMMUNITY DEVELOPMENT:

1. Family members involved in at least one legitimate people’s organization / community development:
____ yes_X___ no
2. Number of family members involved: ___N/A____
3. Name in organization involved in (specify):
______________________________________N/A____________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

4. Awareness in existing organizations:

List name of organizations known to be respondent even if not a member:
__UB,
YWAM______________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________

5. Participation in other community activities / projects:

List projects / activities participated in:
______Feeding________________________________________________________________________________
_______Leading_______________________________________________________________________________
_________Teaching____________________________________________________________________________
___________________

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VI. COMMUNITY RESOURCES, NEEDS AND PROBLEMS:

A. MANPOWER:

Recognized leaders / Community members that can be tapped in the implementation of community projects:

NAME POSITION SPECIALIZATION

James Buta Speaker Talks
Rome Santos Pastor Speaking
Kareen Estrella Manager Macro-thinking
Angelica Mendoza Influencer Social media

B. MATERIAL

Identify available material resources in the community that can be used for community projects, specify:
Food, water, metal sheets, discarded metal sheets, discarded furniture, discarded white plastic tables,
discarded white plastic chairs, old books, abandoned homes, river, land space, dirt, compost, soil, rusted
tools, dried out water tanks, discarded clothes, fruit trees, tires, rope, broken glass, banana trees and water
streams______________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________________________________

C. Needs and Problems:

Based on your perception, identify at least 3 most important problems and possible solution that can affect
the health and development of your community”

PROBLEMS RECOMMENDATIONS
Constructing a more linear road/bridge to clear up
Health facility distance traffic congestion. More funding towards air-based
vehicular transport. Advancing jetpack technology
for easy maneuverability over hills only for
emergencies. Suggesting mini-clinics towards the
community preferably on the main roads.
Advancement towards reserved lanes for emergency
vehicles.
Having a shared garden/community garden.
Sustenance Teaching on how to plot, sustain and grow plots of
land for sustainable farming. Provide seeds, enhance
water supply, enrich soil with minerals from the
metal scraps. Grow aesthetic flowers, cash crops
alongside sustenance for a more varied greenery.
Recommending which plants to grow, which not to
grow and how to prioritize which crops to grow as
cash crops may lead to hyper attention. Root out
wild fruit trees and transfer them to a more efficient
space and collection.
Reserve plots of land set aside for the development of
Fitness recreational facilities/units such as parks,
playgrounds, basketball courts, volleyball courts,
tennis courts, public buildings, etc. Implement a
Zumba course that can be free preferably in the
middle fo the community with a possible tall speaker
for music and instructions as well as those leading
Zumba to be experienced or professional- with
professionals leading at the start to cut costs.
Building more stairs and slope as well as safer
version to encourage being walked through- possibly
the plans for more streetlamps to encourage late
evening jogging, strolls, etc. Encourage leashing dogs
to be accompanying jogging buddies.

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