HOUSEHOLD SURVEY FORM

INSTRUCTION: Please provide the answers to the questions below. No questions must be left unanswered. For question/s which
is/are not applicable, kindly write N/A.

I. FAMILY MEMBERS AND CHARACTERISTICS

A. Basic Information About HEAD OF THE FAMILY

Name: _______________________________ Birthdate: _______________ Age: ______ Sex: __________

Highest Educational Attainment: ________________ Occupation: _______________ Monthly Income: __________

Civil Status:

 Married □ Legally □ Common Law

 Widowed
 Separated
 Single

Employment Status:

 Permanent □ Private □ Public

 Temporary □ Casual□ Contractual
 Self-employed
 Unemployed

B. Other Family Members:

No. of children in the household:
Total: _______ Male: _____ Female: _____
No. of other dependents in the household:
Total: _______ Male: _____ Female: _____

RELATION HIGHEST
MONTHL
TO HEAD AG CIVIL EDUCATIONA OCCUPATIO
NAME SEX Y
OF THE E STATUS L N
INCOME
FAMILY ATTAINMENT

**NOTE:
 For children ages 3-5, indicate under educational attainment column whether attending daycare or not.
 For children ages 6-16, state whether currently studying or not under occupation.

II. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

A. Religion: (please specify) ________________________
B. Primary dialect/ language spoken at home: _________________________
C. Income:
C.1 Estimated average family income per month (total family income: from A and B, please check)
Above 50,000______ P30,001-35,000 _____ P10,000-15,000____
P45,001–50,000 ____ P25,001-30,000 _____ P5,001-10,000 ____
P40,001-45,000 ____ P20,001-25,000_____ P1,001-5,000 _____
P35,001-40,000_____ P15,001-20,000_____ P1,000 & below____

C.2 Primary source of Livelihood:

Farming _____ Owned: ____ Tenanted: ____
Laborer: _____ Carpentry: _____
Fishing: ______ Peddling: _____
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 Government Employee: ______
Small Industries: (sari sari store, carenderia, etc. )_____
Others (specify): ____

C.3 Food Production Engaged in (may check more than one): _____ yes, ____no
(if yes, please answer below)

RESOURCES FAMILY SELLING BOTH

CONSUMPTION
Vegetable gardening
Piggery
Poultry
Fruit trees
Others: (pleases specify)
__________________

__________________

D. Real Property
D.1 Type of property owned:
___ Farmland (rice, coconut, others)
___ Residential Lot
___ Residential lot with house
___ Commercial Lot with building
___ Others (Specify)
D.2 Housing:
a. ownership: ___ owned ____ rented ___ shared
b. type of construction:
___ light
___ medium (wooden floors/walls with nipa roof)
___ heavy (dominantly concrete/ hardwood with galvanized sheets)
D.3 Facilities:
a. Type of appliances owned:
___ radio ___ CD ___ Electric Fan
___ cassette ___ DVD ___ refrigerator
___ TV ___ Gas burner ___ Computer Set
___ Laptop ___ Others: (specify) _____________________

b. Vehicles owned: (for people and/or goods)

___ car ___ tricycle ___ others (specify)
___ private jeep ___ motorcycle _____________________
___ truck ___ kuliglig _____________________

c. Utilities
___ Electrical connection

___ Telephone / cellphone

D.4 All family members with basic clothing of at least 3 sets of external and internal clothing:
___ yes ___ no

D.5 Family Consumption:

Family Food Consumption Adequate (please check) Inadequate (please check)

Eat 4 times or more
Eat 3 times a day
Eat twice a day
Eat once a day

E. Decision making pattern (please check the appropriate column, you may check more than one)

DECISION AREA FATHE MOTHE CHILDRE SINGLE

R R N
Family Expenses
Health
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 Education
Participation in Community activities

III. HEALTH STATUS AND PRACTICES

A. Food, nutrition and Immunization Status (children 0-72 months old)

a.1 Infants exclusively breastfed for four months:

Name of Child Exclusively breastfed for 6 months If NO, state reason

YES NO

a.2 Supplementary feeding: (children 0-72 months old)

Name of child Supplementary feeding If yes, what were the types of food given? Age started
Yes No

a.3.1 Nutritional Status of children 0-72 months

Name Birthdate Date of Weight Status Height Status

Weighing

a.3.2 Immunization Status (Children 0-12 months old)

Name Age in Types of Immunization

months BCG OPV1 OPV2 OPV3 PCV1 PCV2 PCV3 IP Penta123 Vit.A MM Status
V R
FIC

CIC

B. Prenatal, Natal and Postnatal Care (to be answered if there were pregnant/lactating mothers and deliveries in
the past year)
1. Pregnant and lactating mothers provided with Iron and Iodine supplementation:
____ yes ___ no
2. Pregnant mothers given at least 2 doses of Tetanus toxoid:
___ yes ___ no
3. Pregnant mother given prenatal care: ___ yes ___ no
3.1 First visit made in the first trimester ___ yes ___ no
3.2 Had at least 1 visit per trimester ___ yes ___ no
3.3 Total number of pre-natal visit: ____

4. Postnatal visit within 4-6 weeks postpartum: ____ yes ___ no

5. Delivery handled by trained health personnel: ___ yes ___ no
If yes, specify: ___ trained hilot
___ RHM
___ Nurse
___ Physician
If no, who handled the delivery? (specify) _______________________
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 C. Family Planning (To be answered by MCRA’s in the household):
1. Couples with access to family planning services: ___ yes ___ no
2. Couples practicing family planning: ___ yes ____ no
If yes, specify method: ________________________
If no, state reason: ____________________________

D. Morbidity (Past 1 year, please counter-check with secondary data)

1. Any of the children below 6 years old had more than 1 diarrheal episodes: ____ yes ___ no
2. Other illnesses experienced by family members:

Type of Illness Age Sex Health worker attended Treatment used

E. Mortality (Past 1 year, please counter-check with secondary data)

1. With deaths in the family due to preventable diseases (past 1 year): ____ yes ____ no
2. Causes:

Type of Illness Age Sex Health worker attended Treatment used

F. Health Seeking behavior and Utilization of Health Services:

1. Family member with Phil health:

Name Status Remarks

2. Family members avail of health services: ___ yes ___ no

3. With solo parent availing health services: ___ yes ___ no
4. Delays in accessing health care
a. Reasons in delaying decisions to seek health care:
___ Failure to recognize danger signs
___ lack of money to pay expenses
___ No available person to take care of the children and home
___ Lack of companion in going to the health facility
___ others; specify _________________________
b. Reasons for reaching appropriate care in a health facility
___ Distance of home to a health facility
___ Lack of transportation
___ others: specify _____________________________
c. Delays in Receiving appropriate care in a facility
___ Shortages of supplied and basic supplement in a health facility
___ lack of skilled health personnel in the hospital
___ Poor skills of health care providers
___ Others: specify ________________________________
5. Health services most frequently availed of: (please rank)
___ RHU ___ Private Clinic
___ BHS ___ Hospital ___ private ___ public

6. Health worker preferences during illness (rank using numbers according to who is seen first)
___ Medicine man ___ Nurse others: specify ________________
___ Midwife ___ Doctor
7. Health interventions done during illness (Rank using numbers according to who is seen first):
___ Self-Medication: Specify ____________________
___ Consult medicine man (Albularyo)
___ Consult RHM
___ Consult Nurse
___ Bring Patient immediately to the hospital
___ Others: specify ________________________
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IV. ENVIRONMENTAL CONDITION
a. Safe water
1. Access to safe drinking water within 250 meters or 10 minutes’ walk from their home:
___ yes ___ no
2. Water source (please check):
Level 1: ____ Protected well
____ Developed spring
Level 2: ____ Piped distribution network and communal faucet
Level 3: ____ Waterworks system for individual households
Others: ____ Shallow dug well
____ Unprotected spring
____ Others: (Specify) ______________________________
3. Method of water storage: ____ open container ____ covered container
4. Method of water treatment: ____ chlorination ____ boiling ____ no treatment

b. Method of Excreta Disposal:

Types: ____ WST owned:

___ functional ____ non-functional

____ WST shared:
___ functional ____ non-functional
____ without, specify: _________________________________

c. Method of Domestic Water waste Disposal: ___ Blind drainage ___ Open Drainage

d. Method of Garbage collection and disposal (common HH practices):

Collection: ____ open receptacle ___ none
____ covered receptacle

Disposal: ____ composting ____ burying

____ burning ____ open dumping
____ riverside dumping ____ others

e. Method of animal management:

Kind of animals: specify: _____________ ___domestic _____ agricultural
_____ tied ____ fenced ____ astray
_____ both ____ no animals
f. Food Storage:
____ cabinet ___ covered plates ___ others: specify
____ covered basket ___ refrigerator ____________________

V. PEOPLES PARTICIPATION IN COMMUNITY DEVELOPMENT:

1. Family members involved in at least one legitimate people’s organization / community development:
____ yes____ no
2. Number of family members involved: _______
3. Name in organization involved in (specify):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________

4. Awareness in existing organizations:

List name of organizations known to be respondent even if not a member:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________

5. Participation in other community activities / projects:

List projects / activities participated in:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________________

VI. COMMUNITY RESOURCES, NEEDS AND PROBLEMS:

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A. MANPOWER:

Recognized leaders / Community members that can be tapped in the implementation of community projects:

NAME POSITION SPECIALIZATION

B. MATERIAL

Identify available material resources in the community that can be used for community projects, specify:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
__________________________________________________________________________________

C. Needs and Problems:

Based on your perception, identify at least 3 most important problems and possible solution that can affect
the health and development of your community”

PROBLEMS RECOMMENDATIONS

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