Barangay Profile Survey Form

NO: __
HOUSEHOLD NO.________ DATE OF INTERVIEW: ______________
ZONE: _______ Barangay: ____ Purok: _______ Interviewer: _____________

I. Family members and characteristics

A. Basic information about the head of the family:
Name(husband): _________________________________________________ Age: _______ Sex: _____
Status: Occupation: __________________________
married Employment Status
widowed Permanent (__Private) (___Government)
separated Self Employed
single Unemployed Temporary
live-in or unmarried couple

WIFE: Age: Occupation: .

HIGHEST EDUCATIONAL ATTAINMENT: _

B. Other family members

No. Of children living in household: Male: ___ Female: ___ Total: ___
No. Of other dependents in household: Male: ___ Female: ___ Total: ___

NAME RELATION TO HEAD AGE SEX CS HIGHEST EDUC.

OCCUPATION
OF FAMILY ATTAIN.
___________________________ ____________ ___ ___ ___ _____________________
___________________________ ____________ ___ ___ ___ _____________________
___________________________ ____________ ___ ___ ___ _____________________
___________________________ ____________ ___ ___ ___ _____________________
___________________________ ____________ ___ ___ ___ _____________________
___________________________ ____________ ___ ___ ___ _____________________
___________________________ ____________ ___ ___ ___ _____________________
___________________________ ____________ ___ ___ ___ _____________________
___________________________ ____________ ___ ___ ___ _____________________
___________________________ ____________ ___ ___ ___ _____________________

NOTE: For children ages 3-5 indicate in column on education attainment whether attending day care or not.
For ages 6-12 and 13-16, state whether currently studying or not under occupation.

□Yes □No □N/A All family members 10 years old above able to read and right and do simple computation.

II. Socio-economic, Cultural Characteristics

A. Religion________________________________________________________________________
B. Primary Dialect/ Language spoken at home___________________________________________
C. Income________________________________________________________________________
C.1 Estimate Average Family income per month (total from all sources)
___Above 50,000 __________ 30,0001-35,000 __________ 10,001-15,000
___45,001-50,000 __________ 25,001-30,000 ___________ 5,001-10,000
___40,000-45,000 __________ 20,0001-25,000 __________ 1,001-5,000
___35,000-40,000 __________ 15,001-20,000 __________ 1000 below
 C.2 Primary Source of Livelihood ___Owned ___Tenanted

___Farming ___Tuba Gathering

___Fishing ___Small Industries (sari-sari store, Karenderia,etc)
___Laborer ___others(specify):
___Peddling _________________________________________
___Carpentry ________________________________________

C.3 Other Sources of income (may check more than one)

Resources Family Selling

Vegetable gardening __________ __________

Poultry __________ __________
Piggery __________ __________
Fruit Trees __________ __________
Others __________ __________

D. Real Property
_____ Farm Land (rice, coconut, others) _____Residential Lot
_____ Residential lot w/ house _____Commercial lot w/ building
____ others (specify)

D.2 Housing

a) ownership: ___owned ___owned ___ rented ___ shared

b) Type of construction:
____light _____medium (wooden floors/walls with nipa roof)
____heavy (dominantly concrete/hardwood w/ galvanized sheets)

D.3 Facilities
a) Type of appliances owned
___radio ___CD ___electric fan ___cassette ___ gas range
___ Television ___refrigerator ___VCR ___Stereo ___others
b) Transportation owned
___car ___private jeep ___passenger jeep ___tricycle ___motorcycle ___ trucks
___others (specify):
_____________________________________________________
d) Internet connection: ___ Yes ___No

D.4 All family members with basic clothing of at least 3 sets of external and internal clothing
__Yes __No

Decision Making Pattern

Decision Area Father Mother Children

Family Expenses ________ _______ ________

Health ________ _______ ________
Education ________ _______ ________
Participation In Community Services ________ _______ ________

III. Health Status and Practices

A. Food, nutrition and immunization status (children below 5 years old)
A.1 Newborn with birthweight of at least 2.5 kg: ___Yes ___ No ___Not Applicable
A.2 Infant exclusively breastfeed for four months. ___ Yes ___ No ___ Not Applicable
A.3 Supplementary Feeding: ___ Yes ___ No
 A.3.1 Types of food given: (enumerate) Age Started
___________________________ _____________
___________________________ _____________
___________________________ _____________
___________________________ _____________

A.4 Is there at least one moderate or severely underweight member of the family aged below 5 years
old?
___Yes ___No ___Not Applicable

A.4.1 Nutrition and immunization status (children 0-5 years old)

NAME AGE YELLOW WEIGHT NUTRITIONAL STATUS IMMUNIZATION STATUS

CARD

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 mother given at least two 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 one visit per trimester
Total number of prenatal visit _______________________
4. Postnatal visit within 4-6 weeks postpartum. ___Yes ___No
5. Delivery handled by well-trained health personnel. ___Yes ___No
If yes, specify method
____________________________________________________
If no, state reason
____________________________________________________
B. Family planning (to be answered by MCRA’s ages 15-49 years old in the household)
1. Couples with access to family planning services? ___Yes ___No
2. Couples practicing family planning? ___Yes ___No
3. If yes, what is the Family Planning Method? ___________________________
C. Morbidity (past year)
1. Any of the children below 5 years old had more than 3 diarrheal episodes in a year? ___Yes __No
2. Other illnesses experienced by family members

Type of illnesses Age Sex Health Worker Attended Treatment Used

_________________ _____ _____ _______________________ __________________
_________________ _____ _____ _______________________ __________________
_________________ _____ _____ _______________________ __________________

D. Mortality (past year)

1. With deaths in the family due to preventable diseases? (past year). ____yes __no __N/A
2. Causes

Cause of death Age Sex Health Worker Attended Treatment Used

_________________ _____ _____ _______________________ __________________
_________________ _____ _____ _______________________ __________________
_________________ _____ _____ _______________________ __________________
 F. Health seeking behavior and utilization of health services
1. Family members avail of health services ___Yes ___ No
2. With solo parent availing health services ___Yes ___ No
3. Health services more frequently availed of:
___ RHU ___BHS ___ Private Clinic ___ Hospital ___ Govt. ___ Private
4. Health worker’s preferences during illness: (rank according to who is seen first)
___Medicine Man ___ Midwife ___ Nurse ___ Doctor ___others
5.Health intervention done during illness: (rank using numbers according to priority)
___ Self-Medication ___ use herbal meds/home remedy ___ used commercially prepared drugs
___ consult medicine man _____Consult RHM ___Consult Nurse ___Bring Immediately to hospital
___ Others: Specify

IV. Environmental Condition

A. Safe Water
1. Access to safe drinking water within 250 meters or 10mins from their? Yes__ No__
2. Water Source (Please Check);
Level I: ___Protected Well ___Develop Spring
Level II: ___Piped Distribution Network and Communal Faucet
Level III: ___ Waterworks System for Individual Household
___Purified Drinking water
Others; ___ Shallow Dug Well ___Unprotected Spring
____Others; Specify, _____________ _____________
3. Methods of water storage; ___covered Container___ Open Container
4. Method of water treatment; ___Chlorination ___Boiling ___ No Treatment
B. Excreta Disposal
1. With Sanitary Excreta Disposal: __Yes ___No
If Yes, ____level 1___level 2 ____ level 3
If No, specify method of excreta disposal: ______________

C. Method of Domestic Water Waste Disposal: ____ Blind Drainage ___Open Drainage
D. Method of Garbage Collection and Disposal:
Collection: ____Open Receptacle ______Covered Receptacle ____None
Disposal ___Composting ___Burning___ Burying
___Riverside Dumping ___ Open Dumping ___ Others
E. Method of Animal Management: __Tied/Fence ___Astray ___No Animals
F. Food Storage: ___Cabinet ___Covered Basket ___ Covered Plates ___ Refrigerator
____Others (Specify):_________________
V. PEOPLE’S PARTICIPATION IN THE COMMUNITY DEVELOPMENT
1. Family members involved in at least one (1) legitimate peoples or
organization/Association/community development. ___Yes ___No
2. Number of Family involved._______
3. Name of the Organization involved in (specify) ____________________________________
____________________________________
____________________________________
____________________________________
4. Awareness in existing Organization. ___Yes ___No
5. List name of organization known to respondent even if not a member
_____________________________________________________________
____________________________________________________________
____________________________________________________________
6. Involvement in Elections
All qualified family members able to vote in the last election ___yes ___No
VI. FAMILY CARE/PSYCOLIGICAL NEEDS
1. With any children below 18 years old engaged in hazardous occupation ___yes ___No ___NA
If Yes, Specify: ___Construction work __Mechanized Farming ___Machines ___Explosives
_____Biologic Agents (Specify)_________
_____pesticides (Specify)_________
_____ Other occupational hazards: _________________________________
2. Any incidence of domestic violence in the family. ___yes ___No
3. Any of the children below 7 years old left unattended. ___yes ___No

VII. PEACE AND ORDER/PUBLIC SAFETY

1. With family member victimized by crime against person? ___yes ___No

2. With family member victimized by crime against property? ___yes ___No
a. Specify :______________________________
3. With family member displaced by a natural disaster? ___yes ___No
a. Specify :______________________________
4. With family member victimized by armed conflict? ___yes ___No

VIII. COMMUNITY RESOURCES NEEDS AND PROBLEMS

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
project.

C. Needs and problems

Based on your perceptions, identify the three
most important problems and possible solution that can affect the health and development
of your community.

PROBLEMS RECOMMENDED SOLUTIONS

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_________________________________________________________________________________________
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