I.

Name: Age: Gender:

Demographic Data

( ) Male

( ) Female ( ) Widow

Civil Status: Religion:

( ) Married ( ) Single

Monthly Income: ( ) Php 5,000 - 10,000 ( ) Php 10,000 20,000 ( ) Php 20,000 30,000 ( ) Php 30,000 40,000 Types of Family: Fathers Name: Mothers Name: Sisters Name: Brothers Name: II. Home ( ) Nuclear ( ) Extended

Ownership: ( ) Owned House made of: ( ) Concrete ( ) Semi Concrete ( ) Native ( ) Concrete ( ) Rent

Lightning Facilities: ( ) Electricity III. ( ) Kerosene ( ) Others: ______

Water Supply:

Types of water supply: ( ) Boreholes ( ) Deep Well ( ) Pipe system

Water Source Protected: ( ) Boiled ( ) Filtered ( ) treated

How much water is collected? ( ) 1-10 gal ( ) 10-20 gal ( ) 20- above gal Is water always available? ( ) Yes ( ) No Does everyone have access to water? ( ) Yes ( ) No Does the community know the quality of water? ( ) Yes ( ) No Are there special place for bathing and laundry? ( ) Yes ( ) No IV. Sanitation

Do households have some form of sanitation? ( ) Yes ( ) No What types of sanitation are there? ( ) Segregated ( ) Decomposed ( ) Burning Is solid waste disposed of, or does waste build up in village? ( ) Yes ( ) No If so how is solid waste disposed? ( ) Recycle ( ) Reuse ( ) Reduce Are there stagnant or standing bodies of water in the community? ( ) Yes ( ) No Is there a system of drainage in homes and for the community? ( ) Yes ( ) No

V.

Nutrition

What are the foods that the household usually eat? ( ) meat ( ) Fish ( ) Vegetables ( ) Others _______ What kind of meat that the household usually eat? ( ) Chicken ( ) Pork ( ) Beef ( ) Others _______ What kind of fish that the household usually eat? ( ) Milk Fish ( ) Catfish ( ) Tilapya ( ) Others ______ What kind of vegetables that the household usually eat? ( ) Eggplant ( ) Okra ( ) Ampalaya ( ) Others ______ Is there a market in the community? ( ) Yes ( ) No Is the market cleaned every day? ( ) Yes ( ) No Is the market dirty? ( ) Yes ( ) No Is the meat always fresh? ( ) Yes ( ) No Are the market vendors careful with personal hygiene? ( ) Yes ( ) No If yes what protective materials do they use? ( ) Gloves ( ) goggles ( ) Hairnet ( ) Apron Are they do hand hygiene? ( ) Yes ( ) No Does the market have water supply and sanitation facilities? ( ) Yes ( ) No

VI.

Kitchen

What cooking fuel is used in the community? ( ) Gas stove ( ) Electric ( ) Others ______ Methods of disposal: ( ) Hog feeding ( ) Open dumping ( ) Others ______ VII. Construction

What materials are used for household construction? ( ) Cement ( ) Steel ( ) Wood VIII. Common problems What are the insects common in the community? ( ) Mosquitoes ( ) Flies ( ) Cockroach Common diseases in the community? ( ) Coughs and colds ( ) Fever ( ) Diarrhea ( ) Others _______ IX. Domestic Animals

What domestic animals kept in your home? ( ) Dog ( ) Cat ( ) Hen/Rooster ( ) Others _________