Initial Data Base: Family Member No
Initial Data Base: Family Member No
Initial Data Base: Family Member No
Date Interviewed:
Head of the Family: Family No.:
Address:
Type of Family Structure:
__________________________________________________________________
1. Home
a. Ownership: ( ) Owned ( ) Rental ( ) real-Free
b. Construction Materials used: ( ) Light ( ) Mixed
c. Number of rooms used in sleeping: _______
d. Lightning Facilities: ( ) Electricity ( ) Kerosene ( ) Others Specify: _____
e. General Sanitary Condition: _______________________________________
2. Water Supply
a. Drinking Water
Source: ( ) Private ( ) Public
Distance from the house: ____________
Storage: ( ) none (direct from faucet or pipe)
( ) Jar or can with faucet
( ) Jar or can without faucet
( ) Others (specify) ________________
3. Kitchen
a. Cooking Facilities: ( ) electric stove ( ) gas stove ( )firewood
b. Sanitary Condition: _____________________
c. Drainage Facility: ( ) none ( ) open drainage
4. Water Disposal
a. Refuse Garbage
1.) Container: ( ) covered ( ) open ( ) none
2.) Method of Disposal:
( ) Hog feeding ( ) Composing
( ) Open Dumping ( ) Incineration
( ) Open Burning ( ) Others Specify: __________
( ) Basal in Pit
b. Toilet
1.) Type
( ) None ( ) Antipolo System
( ) Pail System ( ) Water-sealed Latrine
( ) Open pit privy ( ) Flush Type
( ) Closed pit privy ( ) Overhung latrine
( ) Bored-hole latrine ( )Others Specify: __________
2.) Distance from the house: _______________________________________
3.) Sanitary Condition: ____________________________________________
5. Domestic Animals
Kind Number Where Kept
_______________ _______________ _______________
_______________ _______________ _______________