St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

COMMUNITY ASSESSMENT FORM

Respondent: _________________________________________________ Age: _______________

Stage: _______________________________________________________Sex: _______________
Relation to Head: __________________________________________ (If not, the Head of the Family)

I. Family Data
A. Head of the family: _____________________________________ Age:____________________
B. Name of Spouse:_______________________________________ Age:____________________
C. Address:______________________________________________Tel No.__________________
D. Educational Attainment:__________________________________________________________
i. Husband:_____________________________________________________________
ii. Wife:________________________________________________________________
E. Length of Residency:____________________________________________________________
F. Ethnic Origin:__________________________________________________________________
G. Family
Nuclear: ____Extend: _____Cohabitation: _____ Single Parent: ____ Gay/Lesbian: ________
H. Religion
Roman Catholic: ___Muslim:____Iglesia Ni Kristo: ___Born Again: ___Protestant:___Others:__
I. No. of Children_________________________________________________________________
J. Members of the Household

Name Relation to Age Sex Status Education Occupation

the Head
II. Socio-Economic Data
A. Source of Income
Occupation
Husband
Employed: ________ Unemployed: __________ Self-employed:___________
Wife
Employed: ________ Unemployed__________ Self-employed:___________
Joint Monthly Income
Below ₱2,000:__________ ₱ 3,000 - ₱5,000:___________
₱5,001 - ₱8000:_________ More than ₱8,000:__________
B. Basic Expenditures:
1. Food daily
Below ₱ 100:_____________ ₱150-250:__________________
More than ₱ 100:___________ More than ₱250:_____________
2. Clothing: number of times of buying in a year
Once: ___________________ Twice: ________________________
Thrice: __________________ More than four times: ____________
3. Housing
Water: _______________ Electricity: ___________
Telephone: ____________ Internet: _____________
4. Schooling
Public: _____________ Private: ____________Others:_____________
C. Food Preference:
Fish: ____________ Fruit/Vegetables: __________ Junk foods: _________
Meat: ___________ Bread: __________________ Pasta: _____________
D. Containers Used:
Plastic: _____________ Jars: _______________Wood:____________________
Bottles: _____________ Metal: ______________Others:____________________
E. Toilet Facilities
Sanitary:
Flush: ______________Pit Latrine: ___________Septic Tank: ___________________
Antipolo Toilet: _______Aqua Privy: ____________Overhung Latrine: _____________
Ventilated-improved privy: __________________Compost Privy: _________________
Pour-flush latrine: ________Tank-flush toilet: _________Box and Privy: _____________
F. Waste Disposal:
Collection: ____________________ Burning: ______________________________
Compost Pit: ___________________ Open Dumping: ________________________
G. Food Storage:
Covered: _____________________ Uncovered: ___________________________
Refrigerated: __________________
H. Presence of Animals:
Dogs: ________________________ Cats: ________________________________
Pigs: _________________________ Chicken: ______________________________
Birds: ________________________ Fish:_______________Others:____________
I. Backyard Gardening:
Vegetables:___________________ Herbal:_______________________________
Fruit-bearing:__________________ Others:_______________________________
J. Community Observation:
a. Sanitary Condition:______________________________________________________

b. House overcrowding/congestion: Yes ( ) No ( )

c. Presence of breeding sites of vectors: Yes ( ) No ( )
If yes, specify: _________________________________________________________
d. Health facility: Hospital:__Health Center:___Private Clinic:___Albularyo:__Others:_____
 e. Recreational facility: _____________________________________________________
f. Distance of house to the nearest health care facility: ____________________________

K. Common Fare
Rice and egg:_______________ Rice and vegetables:_____________________
Rice and meat:______________ Rice and fish:__________________________

III. Housing and Environmental Condition

A. Home
1. Type of Housing
Concrete:_________________ Wood:__________________________________________
Mixed (Concrete & Wood): ____________Makeshift:_____________Others:____________
2. Ownership
Owned:___________________Rented:_________________________________________
Rent-free:_________________Others: _________________________________________
3. Numbers of rooms for sleeping: ________________________________________________
4. Ventilation:
Poor:____________________Fair:_____________Good:__________________________
5. Lighting facilities:
Electricity:_________________Kerosene:_______________________________________
Solar Panel: ______________________________________________________________
6. General surroundings:
Clean:____________________Dirty:___________________________________________
B. Source of Water Supply:
Deep well:________________Faucet:_______________Waterwork system:___________
C. Storage of Drinking Water:
Refrigerated:_________________Covered:_____________________________________
Uncovered: __________________Others:______________________________________
D. Kitchen:
Electric stove_________________Gas stove____________________________________
Firewood/charcoal_____________Others_______________________________________
E. Drainage:
Open________________________blind________________________________________
None____________________________________________________________________
Sanitary observations:
______________________________________________________

IV. Immunization Status of Children

BCG:______________ OPV:___________ DPT:____________ Pentavalent:____________
Hepa B:____________ AMV:___________ Rotavirus:________

V. Methods of Family Planning

IUD: _____________ Ligation: __________ Pills: _____________
Rhythm: __________ Withdrawal: ________ Condom: __________

VI. Health Information

Health Personnel______ Social Media_______ Radio____________
Television____________ Newspaper/Fliers/Posters_____ Phone____________
Others specify: _____________________________________________________________________

VII. Type of Birth Attendant

Doctor: __________ Midwife: _________ Nurse: __________ Trained Hilot: ______

VII. Mortality: ________________________________________________________________________

IX. Morbidity: _______________________________________________________________________

Data on Community Development
A. Health Problems of the Community

Ranking Problems No. Identified

1
2
3

B. Causes and Possible Solutions

C. Other needs of the Community

Ranking Problems No. Identified

1
2
3

D. Solutions to the needs of the Community

Guidelines in Making Tables and Analysis
Table 1
Percentage Distribution Showing the Age of Families Surveyed,
Barangay___________. Purok/Sitio/Zone_______________as of 2020

Age Category Male Female Total %

0-1 Neonate
2-11 Infant
1-3 Toddler
4-5 Pre-School
6-10 School Age
11-14 Early Adolescence
15-17 Middle Adolescence
18-20 Late Adolescence
21-40 Young Adult
41-60 Middle Adult
>60 years Old Adult
Total

Table 2
Percentage Distribution Showing the Sex Distribution of Families Surveyed,
Barangay___________. Purok/Sitio/Zone_______________as of 2020

Category F %
Male
Female
Total

Table 3
Percentage Distribution Showing the Sex Distribution of Families Surveyed,
Barangay___________. Purok/Sitio/Zone_______________as of 2020

Category F %
Nuclear
Extended
Cohabitation
Single Parent
Gay/Lesbian
Total
 Guide to Table Interpretation

100% All of the respondents

97%-99% Almost all of the respondents
86%-96% Most of the respondents
76%-85% Great Majority of the respondents
51%-75% Majority of the respondents
50% Half of the respondents
49% and below A great percentage of the respondents
A great number of respondents
 St. Paul College of Ilocos Sur
(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

DEPARTMENT OF NURSING

COMMUNITY ORGANIZING
PARTICIPATORY ACTION RESEARCH
(Location)

A Family Case Study Presented to the Faculty of

Department of Nursing, College Department

In Partial Fulfilment of the Requirements in

Community Health Nursing I
A.Y. 2020-2021

Submitted to:

Submitted by:
Melanio P. Rojas Jr
MELANIO P. ROJAS JR. BST, RM,RN, MAN
 Month and Year

TABLE CONTENTS

Title Page
Approval
Dedication i
Acknowledgement
List of Tables
List of Figure
Vicinity Map
Spot Map
Chapter I. Introduction 1
Rationale
General Objectives
Specific Objectives
Methodology/Tools Used
Limitation of Study
Chapter II. Community Profile
Barangay Profile
Purok Profile
Chapter III Presentation, Interpretation and Analysis of Data Gathered
Community Data
Chapter IV Data on Community Development
A. Health Problems
B. Causes and Possible Solutions
C. Other needs of the Community
D. Solutions to the needs of the Community
 Chapter V. Community Problems and Justification
A. Problem Prioritization
B. Community Health Care Plan
Chapter VI. Learning Journal
Chapter VII. Documentation
Appendices
Family Questionnaire Checklist
Curriculum Vitae
Community Health Problem Prioritization
1. Poor environment sanitation as health threat namely:
 Improper garbage disposal
 Air pollution
 Poor drainage
 Noise pollution

Criteria Computation Score Justification

1. Nature of the 2/3 2/3 It is a human threat
problem

2. Modifiability ½x2 1 The community does not

of the have adequate resources
problem to solve the problem.
However, student can give
suggestions and conduct
health teaching.

3. Preventive 1/3 x 1 1/3 The problem on poor

potential drainage system and
garbage disposal can
minimized but air and
noise pollution and poor
ventilation needs financial
and government support in
order to totally prevent the
problem.

4. Salience 2/2 x 1 1 The community

recognizes the problem as
serious and needs
immediate attention.

Total 3
 Community Problems According to Priority

Family Problems According to Priority

1 Poor Environmental 3 2/3
2
3

Community Case Plan

1. Poor environment sanitation as health threat namely:
 Improper garbage disposal
 Air pollution
 Poor drainage
 Noise pollution
Cues Analysis Goal of Care Objective of Care Nursing Rationale Method of Evaluation
of the Intervention Contact
Problem
After nursing After ___ hours of 1. Set a time Home visit
intervention……. home visit the ff. for
To be consciously conductin
S
aware of these 1. The g
problems and find community programs
possible solutions, will practice of
prioritize, garbage recycling
O immobilize their segregation
resources and
cooperate with one
another.
 CHAPTER I

INTRODUCTION
 CHAPTER II
COMMUNITY PROFILE