Extension Form No.

4 Barangay Management Information System Questionnaire

House No._____ Street/Subd. _____________________ Household Head (Puno ng Pamilya)
SURVEY YEAR: ___________ Purok/Sitio: ________ Barangay: _________________ HH Head’s First Name: _________________ Qualifier ____
 Resident (Residente) Municipality: _______________Province:______________ HH Head’s Middle Name: ________________ Owner
 Non-Resident (Hindi Residente) HH Head’s Family Name: ________________ Extended

ENVIRONMENTAL SANITATION INFORMATION:

Number of family members (Bilang ng Miyembro ng Pamilya):_______ Uri ng Palikuran: Pinagtatapunan ng Basura:
Year first resided in the barangay (Unang Taong nanirahan sa bgy):_______  Owned, water-sealed, sewage/ septic tank  Open-pit  Collected/Burned/
Place of origin (Lugar ng Pinanggalingan): ________________________  Shared/Public, water-sealed, sewage/septic tank  Collected Composting
 Owned Open-pit (Sarili, hukay walang takip)  Thrown Anywhere  Burned/Composting
Telephone Company Contact Number  Shared Open-pit (Nakikigamit, hukay walang takip)  Burned  Open-pit/Burned
 Thrown Anywhere  Composting  Collected/Composting
 Others (Pail system etc.)  River  Collected/Open-pit
 Owned Close-pit (Sarili, hukay n may takip)  Collected/Burned  Collected/Burned/Open-pit
 Shared Close-pit (Nakikigamit, hukay n may takip)  Others
Vehicle Ownership (Pag-aari na Sasakyan) Pinagkukunan ng Tubig:
Vehicle Number Vehicle Number Uri ng Materyales ng Bahay:
 Private Dug well (Balon)  Mineral water, Private Dug well
3-Wheel AUV  Makeshift/salvaged/improvised  Galvanized iron/aluminum
 Public Dug well (Balon)  Mineral water, Public Dugwell
Jeepney Bicycle  Own use, faucet, community  Mineral water, Own use,  Wood  Asbestos/glass/others
Car Motorcycle  Bamboo/sawali/cogon/nipa  No walls/not reported
water system faucet, community
Owner Type Jeep Pedicab  Shared, faucet, community  Mineral water, Shared, faucet,  Concrete/brick/stone
Tricycle Boat  Half Concrete/brick/stone and
water system community
 Own use, tubed/piped deep  Mineral water, Own use, half wood
Truck Motorboat
Pick-Up Bus well tubed/piped dee
 Shared, tubed/piped deep well  Mineral water, Shared, Pag-aari sa Bahay:
Van Coaster
 Being occupied for free w/ consent of owner
Pump Boat Yacht  Own use, tubed/piped shallow tubed/piped deep
well  Mineral water, Own use,  Rented
Raft Others  Owned/Being Amortized
 Shared, tubed/piped shallow tubed/piped sha
well  Mineral water, Shared,  Being occupied for free w/o consent of owner
HEALTH INFORMATION:  Government Property
 Spring, Lake, River, Rain etc. tubed/piped shall
Planting herbal plants (Halamang Gamot)? Yes No  Peddler  Mineral water, Spring, Lake,  PNR Lot
If yes, what herbal plants (Halamang Gamot)?  Others
 Others River, Rain
_____________________ _____________________  Mineral water, Peddler
_____________________ _____________________ Yari ng Bahay:
Pinagkukunan ng Pailaw:  Multi-unit Residence (3 units or more)
 Single House
Do you have backyard garden? Yes No  MERALCO  BIOGAS
 NAPOCOR  Solar Power  Duplex
 Extension
Do you use iodized salt? Yes No  Sariling Generator  No Electricity
 Baterya  Other Independent/Local  Other Housing unit
 Commercial/Industrial/Agricultural
 Barangay Generator Power Producer, specify.
Do you practice Family Planning? __________________________  Institutional Living Quarters
Yes No Not Applicable (Di Naayon)  Not reported
Uri ng Pailaw:
Uri ng Gamit sa Pagluluto:
If yes, what method? (Please check)  Kerosene (Gaas)  Shared Electric Meter
Natural Artificial  Candle  Generator
 Kerosene (Gaas)  LPG/Wood
Rhythm Condom Ligation  Own Electric Meter  Battery
 Wood  LPG/Electric
Temperature Pills Vasectomy  Solar Power  Oil
 Electricity  Charcoal/Wood
 Others
Withdrawal IUD Others  LPG  LPG/Charcoal
Others Depo Injection  Charcoal  None
 Others