12

Baseline Census for the No.

Establishment of
Registry of Barangay
Inhabitants & Migrants Institutional
Household Living
(RBIM) Quarter

Magandang umaga/hapon po. Ako po ay si ______. Ako po ay ______ sa ating barangay.

With technical assistance from the Kami po ay nag-i-interview ng lahat ng households sa ating barangay upang kumulekta ng
impormasyon tungkol sa socio-economic na kondisyon at tungkol sa migration. Ito po ay
makakatulong para magkaroon ng Census ang ating barangay. Nais po sana namin na
humingi ng kaunting panahon upang sagutan ang aming mga tanong tungkol sa inyong
household at mga miyembro nito. Sinisiguro po namin na lahat ng inyong sagot ay kum-
pidensyal. Pwede po ba naming hingiin ang inyong pahintulot na kayo ay ma-interview?

A. IDENTIFICATION
Province Name of Respondent

City/Municipality Household Head

Barangay Total No. of Household Members

Address
(Room/Floor/Unit No. and Building Name) (House/Lot and Block No.) (Street Name)

B. INTERVIEW INFORMATION
Result Name of Name of
C=Completed
Date of Time Time CB=Callback Date of Interviewer, Supervisor,
Visit Visit start end R=Refused Next Visit Initial/Date Initial/Date
1st visit

2nd visit

Baseline Census for the Establishment of C. ENCODING INFORMATION

Registry of Barangay Inhabitants and Migrants (RBIM)
Name and Initial of Name of Supervisor,
Date Encoded Encoder Initial and Date
 2 11

THE HOUSEHOLD
A. DEMOGRAPHIC CHARACTERISTICS

FOR ALL HOUSEHOLD MEMBERS <Do not ask, observation only> 0 No walls
Q53 Construction materials of the outer wall 1 Makeshift/salvaged/improvised materials
2 Glass
Q1 Q2 3 Asbestos
NAME Q5 Q6
RELATION- Q3 Q4 4 Bamboo/Sawali/Cogon/Nipa
DATE OF PLACE OF
SURNAME, FIRST NAME, MIDDLE NAME SHIP TO SEX AGE 5 Galvanized iron/aluminum
BIRTH BIRTH
OR MIDDLE INITIAL HHH 6 Half concrete/brick/stone and half wood
7 Wood
Who are the members of this household What is Is __ How old When was Where was __ 8 Concrete/brick/stone
starting from the HH head? __’s male or is __ as __ born? born? 9 Others, please specify ________________
relationship female? of his/her not, what is
Q54 Do you have any female HH member who died in the
LINE to HH last MM/YYYY City or Age: ____
past 12 months? How old is she and what is the cause of
LIST head? birthday? Municipality nationality?
her death? Cause of death: ______________________
NO. and Province

1 Q55 Do you have a child HH member below 5 years old Age: ____
who died in the past 12 months? How old is she/he? What
Sex: _____
is the cause of her/his death?
2 Cause of death: ______________________
Q56 What are the common diseases that causes death in 1. _________________________________
this barangay?
3 2. _________________________________
3. _________________________________
4 Q57 What do you think are the primary needs of this 1. _________________________________
barangay?
2. _________________________________
5 3. _________________________________

Q58 Where does your household intend to stay five years Barangay: __________________________
6 from now?
Municipality: _________________________
Province: ___________________________
7
PAHINTULOT
8
Lubos kong naunawaan ang layunin ng pananaliksik at Census ng barangay. Nabasa ko at pinaliwanag sa
akin ang nilalaman ng kasulatan at kusang loob akong sumasangayon na makibahagi sa proyektong ito.
9 Naunawaan kong magiging kompidensiyal ang lahat ng aking kasagutan. Gayunpaman, pinahihintulutan
ko ang paggamit ng aking impormasyon ng barangay kalakip ng paggalang sa aking “data privacy rights”.
10
Pangalan at Lagda ng Nakapanayam
NOTES: Q2 Relationship to Household Head Q3 Sex Q6 Place of Birth
For SKIPPED questions, write 99 Male = 1 Write the response
Head = 01 Mother = 12 Female = 2 PAHAYAG SA PAGLILIMBAG
Q1 Name Spouse = 02 Brother = 13 Q7 Nationality
List HH members in this order: Q4 Age
Son = 03 Sister = 14 Filipino = 1 Ang resulta ng proyektong ito ay gagamitin ng ating barangay para sa pagpaplano ng mga programang
 Head Daughter = 04 Uncle = 15 Write the age as of
Non-Filipino = 2 makakatulong sa pagpapalago ng ating pamayanan. Ito ay maari ring gamitin para sa layong pag-aaral o
 Spouse of Head Stepson = 05 Aunt = 16 last birthday
If not Filipino, please
 Never married children from para sa propesyonal na pagpapahayag. Subalit, walang indibidwal na nakapanayam ang kikilalanin. Kung
Stepdaughter = 06 Nephew = 17 Q5 Date of Birth write 2 then comma
oldest to youngest Son-in-law = 07 Niece = 18 ikaw ay may kung anumang katanungan, maari kang makipag-alam sa ating barangay:
Please indicate the month and the response
 Ever married children, the Daughter-in-law = 08 Other relative = 19 and year of birth. Write
spouse and their families from Grandson = 09 Non-relative = 20 the month in the upper
oldest to youngest
Granddaughter = 10 Boarder = 21 triangle and the year in
 Other relatives Father = 11 Domestic helper = 22
(Brgy. Capt._____________________________ ) sa telepono bilang _________________________________.
the lower triangle.
 Nonrelatives
 10 3

H. QUESTIONS FOR CHARACTERISTICS

A. DEMOGRAPHIC THE HOUSEHOLD
Q45 Do you own or amortize this housing unit occupied by 1 Rent-free without consent of owner FOR 5 YRS &
FOR 3-24 YEARS OLD
your household or do you rent it, do you occupy it rent-free 2 Rent-free with consent of owner ABOVE
with consent of owner or rent-free without consent of owner? 3 Rented
Q11
4 Owned/being amortized
Q7 Q8 HIGHEST Q12 Q13 Q14
Q9 Q10
Q46 Do you own or amortize this lot occupied by your house 1 Rent-free without consent of owner NATIO- MARITAL LEVEL OF CURRENTLY SCHOOL PLACE OF
RELIGION ETHNICITY
hold or do you rent it, do you occupy it rent-free with consent 2 Rent-free with consent of owner NALITY STATUS EDUCATION ENROLLED LEVEL SCHOOL
of owner or rent-free without consent of owner? 3 Rented COMPLETED
4 Owned/being amortized
Where was __ Is __ a What is What is the What is ___’s What is the Is __ currently What type In what
Q47 What type of fuel does this household use for lighting? 0 None Filipino? If ______’s religion of __? ethnicity or is highest level enrolled? of school barangay and
1 Oil (vegetable, animal, others) not, what is current ____ a of education is ___ on? city/municipality
2 Liquefied petroleum gas (LPG) ___’s marital Tagalog, completed by is __ currently
3 Kerosene (gaas) nationality? status? Bicolano, __? attending
4 Electricity Bisaya, etc? school?
5 Others, please specify ________________
Q48 What kind of fuel does this household use most of the 0 None
time for cooking? 1 Wood
2 Charcoal
3 Liquefied petroleum gas (LPG)
4 Kerosene (gaas)
5 Electricity
6 Others, please specify ________________
Q49 What is the household’s main source of drinking water? 01 Lake, river, rain, others
02 Dug well
03 Unprotected spring
04 Protected spring
05 Peddler
06 Tubed/Piped shallow well
07 Shared, tubed/piped deep well
08 Own use, tubed/piped deep well
09 Shared, faucet community water system
10 Own use, faucet community water system
11 Bottled water
12 Others, please specify ________________
Q50a How does your household usually dispose of your 1 Feeding to animals
kitchen garbage such as leftover food, peeling of fruits and 2 Burying
vegetables, fish and chicken entrails, and others? 3 Composting
4 Burning
5 Dumping individual pit (not burned)
6 Picked-up by garbage truck
Q50b Do you segregate your garbage? 1 Yes
2 No
Q51 What type of toilet facility does this household use? 0 None Q8 Marital Status NOTES: Q12 Currently Enrolled
1 Open pit Single = 1 For Q11—If 0 to 4 years old, write 99 Yes, public = 1
2 Close pit Married = 2 For Q12, Q13 and Q14— If 0 to 2 and 25 and above, write 99 Yes, private = 2
3 Water-sealed, other depository, shared Living-in = 3 No = 3 (If No, SKIP TO Q15)
4 Water-sealed, other depository, exclusive Widowed = 4
Q11 Highest Level of Education Completed
5 Water-sealed, sewer septic tank, shared Q13 School Level
Separated = 5 Pre-school = 0
6 Water-sealed, sewer septic tank, exclusive No education = 00 Junior HS graduate = 07
7 Others, specify ________________ Divorced = 6 Elementary = 1
Pre-school = 01 Senior HS level = 08
Unknown = 7 Junior High School = 2
Elementary level = 02 Senior HS graduate = 09
<Do not ask, observation only> 1 Single house Senior High School = 3
Q52 Type of building/house 2 Duplex Q9 Religion Elementary graduate = 03 Vocational/Tech = 10
High school level = 04 College level = 11 Vocational/Technical = 4
3 Multi-unit residential (three units or more) Please write the response
4 Commercial/industrial/agricultural High school graduate = 05 College graduate = 12 College/University = 5
5 Institutional living quarter (hotel, hospital) Q10 Ethnicity Junior HS = 06 Post-graduate = 13 Q14 Place of School
6 Other housing units (boat, cave, others) Please write the response Please write the response
 4 9

A. DEMOGRAPHIC CHARACTERISTICS B. ECONOMIC ACTIVITY

E. MIGRATION INFORM ATION F. COMMUNITY TAX CERTIFICATE G. SKILLS DEVELOPMENT

FOR ALL HOUSEHOLD MEMBERS FOR 15 YEARS OLD AND ABOVEFOR MIGRANTS AND TRANSIENTS FOR 18 & ABOVE FOR 15 & ABOVE

Q41
Q17 Q18 Q40A, Q40B, Q40C Q43
Q15 Q16 DURATION OF
Q1 Q3 Q4 STATUS OF PLACE OF REASON/S FOR Q42A, Q42B SKILLS Q44
MONTHLY SOURCE OF STAY IN
NAME SEX AGE WORK/ WORK/ TRANSFERRING IN THIS CTC INFORMATION DEVELOPMENT SKILLS
INCOME INCOME CURRENT
BUSINESS BUSINESS BARANGAY TRAINING
BARANGAY
Copy from previous response How much is What is the What is the InDoes
what____
barangay
plan What are the reason/s why __ Until when does Does ____ Was the CTC What type of What type of
__’s monthly major source status of and city/ transferred in this barangay? _____ intend to have a valid issued in this skills skills do you
income? of _____’s ____’s work/ municipality is stay in this CTC? barangay? development have?
LINE income? business? ____’s work/ barangay? training is ____
LIST business interested to join
NO. located? in?

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NOTE: For Q15, Q16, Q17 and Q18 Q17 Status of Work/ NOTE: For Q19, Q20 and Q21 Q20 Person who Q40A, Q40B, Q40C NOTES: Q44 Skills
If 0 to 14, write 99 Business If 1 year old and above, write 99 Assisted in the Delivery Reasons for Transferring For Q42A and Q42B—If 0-17 years old, write 99 Please indicate the most prominent skill
Permanent Work = 1 Doctor= 1 Availability of jobs = 1 For Q43 and Q44—If 0-14 years old, write 99
Q15 Monthly Income Q16 Source of Q19 Place of Delivery Refrigeration and Carpentry = 8
Casual Work = 2 Nurse = 2 Higher wage = 2
Please indicate average Income Public hospital = 1 Presence of schools or Airconditioning = 01 Baking = 9
Contractual Work = 3 Midwife = 3 Q42A CTC Information Q43 Skills
monthly income from Employment = 1 Private hospital = 2 universities = 3 Automotive/Heavy Dressmaking = 10
Individually Owned Hilot = 4 Yes = 1 Development
all sources. If employed Business = 2 Lying-in clinic = 3 Presence of relatives and Equipment Servicing = 02 Linguist = 11
Business = 4 If others, please No = 2 Training
per day, ask the actual Remittance = 3 Home = 4 friends in other place = 4 Metal Worker = 03 Computer Graphics = 12
Shared/Partnership write the response If No, write answer and Please indicate the
amount received per Investments = 4 If others, please write the Housing = 5 Building Wiring Painting = 13
Business = 5 SKIP TO Q43. type of skills
day and multiply by Others = 5 response If other reason/s, write Installation = 04 Beauty Care = 14
Corporate Business = 6 development training Heavy Equipment
the number of days the If response is 3, 4 the response Commercial Cooking = 15
household member or 5, SKIP TO Q18 Place of Work/ Q21 Immunization Q42B CTC Information that the HH member Operation = 05 Housekeeping = 16
worked for the month. Q19 Business Please write the vaccine last received by the infant. Mother/ Yes = 1 is interested in Plumbing = 6 Massage Therapy = 17
If NONE, SKIP TO Q19 Please write the response Baby Book or Immunization Card may be used as reference. No = 2 Welding = 7 Others = 18, please specify
 8 5

A. DEMOGRAPHIC CHARACTERISTICS E. MIGRATION INFORM ATION C. HEALTH INFORMATION

FOR ALL HOUSEHOLD MEMBERS FOR MIGRANTS AND TRANSIENTS

FOR 0 TO 11 MONTHS OLD FOR WOMEN 10 TO 54 YEARS

Q39 Q23
Q37 Q38A, Q38B, Q38C Q19 Q20. Q21 Q22 Q24 Q25
Q1 Q3 Q4 RETURN TO FAMILY
DATE OF REASON/S FOR LEAVING PLACE OF BIRTH IMMUNIZA- LIVING SOURCE OF INTENTION
NAME SEX AGE PREVIOUS PLANNING (FP)
TRANSFER THE PREVIOUS RESIDENCE DELIVERY ATTENDANT TION CHILDREN FP METHOD TO USE FP
RESIDENCE USE

Copy from previous response When did __ What are the reason/s why __ InDoes
what____
barangay
plan Where was __ Who attended in What is the How many What family If using FP, Does ____ and
transfer in this left his/her previous residence? to return to delivered? the delivery of last vaccine pregnancies planning method where did they partner intend
barangay? previous __? received by does __ had? does ____ and obtain the FP to use FP
LINE residence? __? How many partner currently method? method? If yes,
LIST MM/YYYY When? child/ren are use? what method?
NO. still living? If no, why not?

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NOTE: For Q37, Q38A, Q38B, Q38C, Q39, Q40A, Q40B, Q40C and Q41 Q39 Return to Previous Residence NOTE: For Q22, Q23 , Q24 and Q25 Q23/Q25 FP Method Q24 Source of FP
If non-migrant, write 99 Yes = 1 (Write response in upper Write 99 if: Female sterilization/Ligation = 01 Government hospital = 1
triangle and the date at the lower Male sterilization/Vasectomy = 02 RHU/Health center = 2
Q37 Date of Transfer Q38A, Q38B, Q38C Reasons for Leaving
triangle)  Male, IUD = 03 Brgy. Health Station = 3
Please indicate the No = 2 (Write response in upper  Female 0 to 9 Injectables = 04 Private hospital = 4
Lack of employment = 01 To live with Parents = 08
month and year the triangle and 99 at the lower triangle)  Female 55 and above Implants = 05 Pharmacy = 5
migrant or transient Perception of better income in To live with Children = 09
other place = 02 Marriage = 10 Pill = 06 If other source, write the response
transferred in the Q41 Duration of Stay in Current Q22 Living Children
Schooling = 03 Annulment/Divorce/ Condom = 07
current barangay. Barangay Ask for the total number of pregnancies the HH
Presence of relatives and friends Separation = 11 Modern natural FP = 08 Q25 Intention to Use FP
Write the month in Write response as provided member had. Write the answer at the upper
in other place = 04 Commuting-related Reasons = 12 Lactational Amenorrhea Method 1 = Yes (Write response in upper triangle
the upper triangle triangle then, ask how many are still living as of (LAM) = 09
Employment/Job Relocation = 05 Health-related Reasons = 13 and FP method at the lower triangle)
and the year in the time of interview and write answer in the lower Traditional = 10
Disaster-related Relocation = 06 Peace and Security = 14 2 = No (Write response in upper triangle
lower triangle. triangle. If none, write 0 in the upper triangle and If none, write 00 and SKIP TO Q25. and reason at the lower triangle)
Retirement = 07 Others = 15, please specify 99 in the lower triangle, then SKIP TO Q23.
 6 7

A. DEMOGRAPHIC CHARACTERISTICS C. HEALTH INFORMATION D. SOCIO-CIVIC PARTICIPATION E. MIGRATION INFORMATION

FOR 10 & FOR 60 & FOR 15 &
FOR ALL HOUSEHOLD MEMBERS FOR ALL HOUSEHOLD MEMBERS FOR ALL HOUSEHOLD MEMBERS
ABOVE ABOVE ABOVE
Q27 Q28
Q31 Q35
Q26 FACILITY REASON Q32 Q36
Q1 Q3 Q4 Q29 Q30 REGISTERED Q33, Q34 LENGTH OF
HEALTH VISITED IN FOR VISIT REGISTERED TYPE OF
NAME SEX AGE DISABILITY SOLO PARENT SENIOR PREVIOUS RESIDENCE STAY IN THE
INSURANCE PAST 12 IN HEALTH VOTER RESIDENT
CITIZEN BARANGAY
MONTHS FACILITY
Copy from previous response What is the What facility What is the Is there a Is there a Is __ a In what In what In what How long is __ <Do not ask>
primary health did __ visited reason for member of the member of the registered barangay is barangay and barangay and been staying in
insurance __ in the past 12 the visit in HH that has any HH that is a solo senior citizen? __ a city/ city/municipality this barangay? Indicate if
LINE have? months? health disability? What parent? Is he/ registered municipality did did __ reside six Non-migrant,
LIST facility? is the disability? she registered? voter? __ reside five months ago? No. of years/ Migrant or
NO. years ago? No. of months Transient

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Q26 Health Insurance Q27 Facility Visited Q28 Reason for Visit Q29 Disability NOTES: Q35 Length of Q36 Type of Resident
PhilHealth paying member = 1 Government hospital = 1 Sick/Injured = 1 If with disability, write the type of For Q31—If 0 to 59 years old, write 99 Stay in Barangay Non-Migrant = 1
PhilHealth dependent of paying RHU/Health center = 2 Prenatal/Postnatal = 2 disability For Q32—If 0 to 14 years old, write 99 Write the number (Response in Q33 and Q34 is the same
member = 2 Brgy. Health Station = 3 Gave birth = 3 If without disability, write None For Q33, Q34, Q35 and Q36—If 0 to 4 years old, write 99 of years and with current residence)
PhilHealth indigent member = 3 Private hospital = 4 Dental = 4 months of stay in Migrant = 2
PhilHealth dependent of Private clinic = 5 Medical check-up = 5 NOTE: For Q30 Q31 Registered Senior Citizen Q33 Previous Residence the barangay. (Response in Q33 and/or Q34 is
indigent member = 4 Pharmacy = 6 Medical requirement = 6 If 0 to 9 years old, write 99 Yes = 1 Write the barangay and city/ Write the year in different with current residence and
GSIS = 5 Hilot/Herbalist = 7 NHTS/CCT/4Ps requirement = 7 No = 2 municipality where household the upper triangle response in Q35 is at least six months
Q30 Solo Parent member resided five years ago
SSS = 6 If other facility, If other reason, and the month in and one day)
Registered Solo parent = 1
Private/HMO = 7 write the response write the response Q32 Registered Voter the lower triangle. Transient = 3
Non-Solo Parent = 2 Q34 Previous Residence
If others, please write the Please write the name of the (Response in Q33 and/or Q34 is
Unregistered Solo Parent = 3
response barangay in which HH member Write the barangay and city/ different with current residence and
is registered as voter. municipality where household response in Q35 is less than six months)
member resided six months ago