Questionnaire on Community Health Nursing

Name of the community/ barangay_________________________________

Location of the community________________________________________
Name of the community health nurse________________________________
Age_______ Sex____ Status_____ Highest Educational Attainment ______________
Number of years as CHN in the present Community_________________________
Number of years as CHN in other communities______________________________
Trainings Attended in relation to Community Health Nursing
Seminar / Workshop

Date (year)

1.

Venue

Sponsoring Agency

Size and Type of Community

Land area: _______

Geographic unit: barrio____ village______ barangay_____

Type of community:

rural_____

urban_______ rurban(suburbs)________

Agricultural_______ industrial________ shanty town______

Informal settlers/squatters_________
Socio-economic class:

Class I____

Natural resources:

forest_____ river____ lake_____ volcano______

sea_____

Class II_____ Class III_____ Class IV

ocean_____ mountain_____ tourist spot_____

II. Demographic profile of the Community

Total Population________

Year when census was taken___________

Population density _____________

sex ratio (male to female) _____________

Age structure (percentage of the population)

0-1year old _________

Widow________

Separated__________

Single parent_________

Widower _______

Divorce___________

Married_________

Annulled________

Total number of families/household_________ Average family size________

Top three ethnic groups according to number or predominance in the community (like
Visayans, Tagalog, Ilokanos, Kapangpangans, Bicolanos, Aetas and etc.).
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________

Top three predominant religions/religious groups/sectors, etc)

1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________

III. Socio-economic Data

Top three main occupation/industries
1. _____________________________________________
2. _____________________________________________
3. ______________________________________________
Other sources of income or community livelihood programs
1._________________________________________________
2. _________________________________________________
Average Family Income: check the bracket and indicate percentage of the population
with corresponding monthly family income.

Below 5,000.00 php

__________________________

Above 5,000.00-10,000.00 php.

__________________________

Above 10,000.00-15,000.00 php

__________________________

Above 15,000.00-20,000.00 php ___________________________

Above 20,000.00-30,000.00 php ____________________________

Unemployment rate___________________________
Percentage of population below poverty level_______________________

Percentage of population who completed;

1. Elementary ________________
2. High school_________________
3. College ___________________

4. Graduate school _____________

5. Never attended school ___________

IV. Epidemiologic Profile of the Community

Top 5 Causes of

Number of Cases

Actions Taken or Suggested Actions/Solutions

MORTALITY

Top 5 Causes of
MORBIDITY

Number of Cases

Actions Taken or Suggested

Actions/Solutions

V. Environmental Health Facilities

Water Supply
Source of supply ____________________
Type of water supply: owned (pose, jetmatic) __________ Bought _____
Shared _________ Others, specify _________
Quality of water________________________________
Waste disposal system: Check the appropriate and indicate the percentage.
Flush _________ Wrap and throw________ Water sealed__________
Pit privy_______

Others, Specify_________________

Refuse/garbage disposal: Check the appropriate answer and indicate the percentage.
Collected___________

Open dumping_____________

Waste segregation_________

Burning_______________

Feeding leftover to animals_________

Burying_________________

Balot tapoin in the river/sewer ____________ Others, specify ___________

Housing: check the answer and indicate the percentage.
Wood ____________

Concrete _________________

Makeshift_______________ Mixed (wood & concrete) ________________

Questionnaire for the Community Health Nurse

As the Community health Nurse, Please answer the questions briefly and
candidly as possible.

1. What are some difficulties/problems that you encountered in the performance

of your roles/duties?
2. What are your suggestions to improve your performance and your workplace?

3. Politely request the Community Health Nurse to fill up the checklist below by
checking the box which indicates his/her corresponding roles and functioning
as a CHN. Attach this form questionnaire on Community Health Nursing.

Name of Nurse: _______________Name of Student Nurse:______________________

Designated Position: _________Place of Assignment__________________________
Date of Interview: ______________________
Roles

CN

HC

CB

ED

CL

AV

MG

RS

Provide knowledge, skills and attitude.

Bring together strengths and weaknesses.
Focus on health teachings.
Key tasks include listening and providing
information.
Providing care skills.
Promote self-care and self-determination.
Predict future phenomenon and modify
interventions
Oversees the training of midwives.
Prepare documents and reports.
Undertakes demographic and
epidemiological surveys.
Refers cases to other members of the
health care team.
Legend: CN=counsellor, HC=home care, CB=collaborator, ED=educator,
CI=clinicians, AV=advocate, MG=manager, RS=researcher