Академический Документы
Профессиональный Документы
Культура Документы
FORM
Respondent:____________________________________________________________ Age:______
Stage:__________________________________________________________________ Sex:______
Relation to Head:_________________________________________________________(If not the Head of the Family)
I. Family Data:
A. Head of the Family:________________________________________ Age:______
i. Husband:________________________________ Occupation:_______________________
ii. Wife:____________________________________ Occupation:_______________________
H. Religion: ________________________
A. Source of Income
Occupation:
Husband:
☐ Employed
☐ Self- Employed
☐ Unemployed
Wife:
☐ Employed
☐ Self- Employed
☐ Unemployed
B. Basic Expenditures
1. Food Daily
☐ Below 50.00 ☐ 50.00- 75.00
☐ 75.00 – 100.00 ☐more than 100.00
2. Clothing: number times of buying in a year
☐ Once ☐ Twice
☐ Thrice ☐more than Four Times
3. Housing
☐ Water ☐ Electricity
☐ Telephone
4. Schooling
☐ Public ☐ Private
5. Others: _________________________________________
C. Nutrition
1. Food Preference
☐ Fish ☐ Fruits/Vegetables
☐ Meat ☐ Mixed
2. Common Food
☐ Rice and Egg ☐ Rice and Sardines
☐ Rice and Noodles ☐Others: __________
A. Home
1. Type of Housing
☐ Concrete ☐ Wood
☐ Mixed ☐ Makeshift
Others: _______________________
2. Ownership
☐ Owned ☐ Rented
☐ Rent - Free ☐Others
6. General Surroundings
☐ Clean ☐ Dirty
☐ Refrigerated ☐ Covered
☐ Uncovered
D. Kitchen
☐ Electric Stove ☐ Gas Stove
☐ Firewood/Charcoal
E. Drainage
☐ Open ☐ Blind
☐ None
☐Sanitary Observation: ____________________________
F. Containers Used
☐ Plastic ☐ Jars
☐ Bottles ☐Others: _______________
Page 2
G. Toilet Facilities
Sanitary:
Unsanitary:
H. Waste Disposal
☐ Collection ☐ Burning
☐ Burying ☐Open Dumping
☐ Garbage Cans ☐ Others: _____________________
I. Food Storage
☐ Covered ☐ Uncovered
☐ Refrigerated
J. Presence of Animals
☐ Dogs ☐ Pigs
☐ Cats ☐Chickens/Roosters
☐ Others: __________________
K. Backyard Gardening
☐ Vegetables ☐ Herbal
☐ Fruit-Bearing ☐Others: __________________
L. Community Observation
A. Sanitary Condition: ______________________________________
B. House Overcrowding/Congestion ☐ Yes ☐ No
C. Presence of breeding sites of vectors ☐ Yes ☐ No
D. Health Facilities: ________________________________________
Page 3