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