SYSTEMS PLUS COLLEGE FOUNDATION College of Nursing Angeles Cty COMMUNITY SURVEY TOOL * Brey: Name of Interviewee: Address: we —_ Type of Family: [] Nuclear | J Extended ' Length of Residency: (] greater than 6 mos. [ ] less than 6 mos, Religion: [] Catholic [Won Catholic, specify. [1 Mixed 1. FAMILY MEMBERS: 7 i Name Position [Age Gender | .Givil | Educational I I i | Status | _Atteinment ! { lee Se nfeeee I Agrenge names of children according te oidinal position ® Position of family mambers should be in relation to the head of the family © Ageisas of last birthday, excem: for those less than one year and should be written iin months © Civil Status: Applicable for tndividuals 1 year’, old and above ‘© Cducational Attainment: conelder only 6 vears ld and abi ‘ (*6 y/o- official start of school age in elemeniwny evel nigdg to DepFd, 2008) ECONOMIC INDICES es Name Type of OccupationIll, HOME AND ENVIRONMENTAL INDICES/ ‘ >. Home and Land Ownership + Typect House ‘Type of Housing Structure {JOwned (Single Attsched []Rented | ()Rent-Free (Single Detached | [squatting | Ventilation | _ ere ving Space | () Adequate | t % [erowded [] Inadequate | [| Candigtight T] not crowded LU others: 7 Food Sources | ‘Status of Food Storage 1 T] Market ; : [sart- sari store | | Uoovered ()Ambulant vendor | (uncovered (others: | Water Supply [Jelectrie stove | Uwaterworks (distributor) {] wood/ charcoal (jetmatic {] “kusinilya” S {] pitcher pump (Lec & Cothers: | {others \ “Storage fer Grinking Water ‘Drinking Water Supply [}bottied — U faucet {pitcher pump Uothers: ‘Method e* Garbage Typ Ee arse sd =I (idlean | i] re npest pit | {J unclean J, ourmng: | age cen | | [oren dumphs | Jenllected ‘ ‘Status of Garbage Container j © Exersta Disposal ~Foliet Facility Ticovered ‘Tjfushtype with i {Juncovered | [) pail system (without |) wrap aid throv | ‘Sanitary Condition of Toilet Facility: | ‘Tider O—~S { | U unclean me | [Towned 1] stagnant | LUshared LU] flowing _ia _/AEAUTH STATUS) HEALTH PRACTICE _1. Family Planning 7 és ____ Status pega a ‘Methods of Family Planning | i (] acceptor | Cpilts { {non- acceptor | Ueondom { ‘ ') thythm method | 1IUD (intra-uterine device) i Hothers: | 2. Type of Birth Attendants (0 3, Place of Delivery (0-12 ) &, Type of Feeding 12 mos) mos) (] breast feeding {] Doctor [] Hospital [bottle feeding (Nurse U private U mixes feeding i) Midwife {government []Hilot + [home 5.1 Immunization status (*children age 0 t0 5 y/o) [rane ee] r Wesiiar | 3 i F =) | Underweight TOveriveigh [Mid | Mod 7. Health Secking Behavior (per family basis) (hospital U health center Uprivate clinic {) herboiaryo or hitots (others, specify: 8. Source of Health information (par faniily basis) {Dhospital U printed materials [health center {J television Uredio ‘others, specifyy 9. Ten Leading Causes of Morbidity (Jan. 1 t0 Dec. ‘ Ai ’ 40, Ten Leading Causes of Mortality (Jan. tte lo. 3 fapamman