Republic of the Philippines

PROVINCE OF AGUSAN DEL SUR

Gov. D.O. Plaza Government Center, Prosperidad

EVALUATION OF FOOD GARDENS AND SANITATION OF HOUSEHOLD WITH MALNOURISHED CHILDREN

PHO-NUTRITION SERVICES

Name of Barangay: Date Evaluated:

Name of Father: Name of the Mother:
Name of the Malnourished Child:
Date of Birth: Age in Months:
Contact Number:

Introduction: We are conducting of sanitation and gardens of household with malnourished children, we want to learn from you on the activities and
/or projects you have been participating in to improve your household food security. We would be grateful of you could answer a few
questions for us:

CRITERIA FOR SUCCESSFUL INTERVENTIONS THAT ADDRESS SCORE REMARKS

ECONOMIC & PHYSICAL ACCESS TO FOOD
I. Presence and Quality of Food Gardens (25%)
- Variety of crops planted based on the 3 food basic food
groups (10)
- Care and Maintenance (5)
- Innovativeness (5)
- How the garden was sustained over time (5)
Sub Total:
II. Other sources of Food Production(15%)
Check the following:
- Growing rice
- Fish pond or cage culture
- Livestock and poulty raising
*if there is, please refer to the criteria for successful

interventions on water & sanitation under the category of

of CLEAN SORROUNDINGS

OTHER SOURCES: please specify:

CRITERIA FOR SUCCESSFUL INTEVENTIONS ON WATER AND SANITATION (30%)

I. Presence of the following:
- Sanitary Toilet (5)
- Availability of soap & water at or near the
toilet area (5)
- Clean Sorroundings (10)
- Availability of fence (5)
- Proper waste segregation and disposal (5)
Sub Total:

CRITERIA FOR SUCCESSFUL INTERVENTIONS THAT ADDRESS FOOD SCORE REMARKS

UTILIZATION (30%)
I. Understanding on nutrition (food safety,
proper food handling and storage, food sources
and its nutrients)
- proper handling of iodized salt & other
fortified food products and staples.
- go, grow and glow food groups etc. (10)
II. Positive behavioral change applied by the
household
- use of available natural & nutritious food
- active community participation
- cooking practices
- hygiene and handwashing etc. (5)
III. Access and proper handling of safe water (5)
IV. Improved nutritional status of children (10)
Sub Total:

TOTAL SCORE:

EVALUATOR:

Signature:

Name:
Agency:
Contact Number: