Community Survey Tool
Community Survey Tool
Community Survey Tool
A. COMMUNITY CORE:
Name: _______________________________________________________
Address: _____________________________________________________
SEX
Male Female
0-28 days (Neonate)
B. COMMUNITY SUBSYTEMS
SOCIO-ECONOMIC FACTORS:
Educational Attainment:
Employment Status:
Occupation: _______________________
Monthly Income:
Communication facilities:
[ ] Telephone [ ] TV
ENVIRONMENTAL FACTORS:
Housing Facilities:
Waste disposal:
Presence of pollutants:
Land: [ ] Landfills
CULTURAL FACTORS:
Health seeking behavior: (First person to approach when family member got sick)
[ ] Family doctor [ ] Health center personnel
[ ] Hilots [ ] others, specify: ______________________
Health manpower: (among the health personnel to whom do you always avail of health services.)
[ ] Doctor [ ] Nurse [ ] Midwife
[ ] Trained hilot/ “BHW” [ ] Sanitary inspector
POLITICAL FACTORS:
Do the barangay officials consult the people regarding decision of major issues?
[ ] Yes [ ] No
Institution present:
[ ] Police station [ ] Hospital [ ] Health center
[ ] Recreational facilities [ ] Fire station