COMMUNITY SURVEY TOOL
HOUSEHOLD #: ______________________________________ DATE INTERVIEWED: _________________
INTERVIEWER/S: _____________________________________
A. COMMUNITY CORE:
Name: _______________________________________________________
Address: _____________________________________________________
Sex: [ ] Male [ ] Female
Civil Status: [ ] Single [ ] Married [ ] Widow [ ] Separated
Religion: [ ] Roman Catholic [ ] Islam [ ] Protestant
[ ] others, specify: _____________________
Dialect: [ ] Tausug [ ] Tagalog [ ] Ilokano
[ ] Chavacano [ ] Bisaya [ ] others. Specify: ______________
Family structure: [ ] Nuclear [ ] Kin Network [ ] Extended
[ ] others, specify: _____________________
Ethnicity: [ ] Tausug [ ] Tagalog [ ] Zamboangueñ0
[ ] Bisaya [ ] others, specify: ______________________
Age group:
SEX
Male Female
0-28 days (Neonate)
29-1 year old (Infant)
1 year & 1 day – 3 year old (Toddler)
3 year & 1 day – 6 year old (Pre-schooler)
6 year & 1 day – 12 year old (School Age)
12 year & 1 day – 19 year old (Adolescent)
19 year & 1 day – 35 year old (Early Adulthood)
35 year & 1 day – 65 year old (Middle Adulthood)
65 year & above (Late Adulthood)
B. COMMUNITY SUBSYTEMS
SOCIO-ECONOMIC FACTORS:
Educational Attainment:
[ ] Elementary [ ] High school [ ] College
[ ] Has not one to school [ ] others, specify: ______________________
Employment Status:
[ ] Employed [ ] unemployed [ ] Self-employed
[ ] others, specify: ________________
Occupation: _______________________
Monthly Income:
[ ] Below Php 1,000.00 [ ] Below Php 5,000.00
[ ] Below Php 10,000.00 [ ] others, specify: __________________
Communication facilities:
[ ] Telephone [ ] TV
[ ] others, specify: ________________
Possessing Electrical Facilities: [ ] Yes [ ] No
ENVIRONMENTAL FACTORS:
Housing Facilities:
Type of housing: [ ] Concrete [ ] Light materials
[ ] others, specify: _______________________
Ownership: [ ] Owned [ ] Rented [ ] others, specify: _____________
Adequacy of living space:
[ ] One room [ ] Three rooms
[ ] More than three rooms [ ] others, specify: _____________
Water supply:
Sources: [ ] Faucet [ ] Artesian well [ ] Deep well
[ ] others, specify: ____________________
Storage: [ ] with cover [ ] without cover
[ ] others, specify: ____________________
Waste disposal:
Human waste disposal:
[ ] Antipolo [ ] Balot system (drop and throw) [ ] Water sealed
[ ] Cat hole [ ] Direct disposal in bodies of water [ ] others, specify: ________________
Refuse disposal: [ ] Burning [ ] Composting [ ] Open pit
[ ] City’s garbage collecting system
Presence of rodents/ insects: [ ] Yes [ ] No
Sewage system: [ ] With septic tank [ ] covered canals [ ] Open canals
Presence of pollutants:
Air: [ ] smoke from vehicles [ ] Odor from garbage/ stagnant water
[ ] Presence of factories
Water: [ ] Chemical/ toxic waste from factories
[ ] Garbage thrown into bodies of water
Land: [ ] Landfills
Noise source: ____________________________
CULTURAL FACTORS:
Health seeking behavior: (First person to approach when family member got sick)
[ ] Family doctor [ ] Health center personnel
[ ] Hilots [ ] others, specify: ______________________
Health practices: [ ] Hilots [ ] Quack [ ] Self medication
[ ] Herbal medications [ ] Hospital [ ] others, specify: _____________
Personal habits/ practices:
[ ] walking barefooted [ ] excessive smoking
[ ] eating raw fish/ vegetables [ ] Frequent drinking of alcohol
HEALTH CARE DELIVERY SERVICES:
Health facilities: (Type of health facilities frequently availed by the community.)
[ ] Hospital [ ] Private clinics
[ ] Health centers [ ] others, specify: ______________
Health manpower: (among the health personnel to whom do you always avail of health services.)
[ ] Doctor [ ] Nurse [ ] Midwife
[ ] Trained hilot/ “BHW” [ ] Sanitary inspector
Health status: Number of children immunized: ____________
Fully immunized: ______ Partially immunized: _______ Not immunized: _______
Common illness experience by the family:
[ ] Cough colds [ ] Diarrhea
[ ] Fever [ ] Constipation
How often do you avail of the services?
[ ] always [ ] often
[ ] sometimes [ ] never
POLITICAL FACTORS:
Do the barangay officials consult the people regarding decision of major issues?
[ ] Yes [ ] No
Are barangay officials actively involved in the community health services?
[ ] Yes [ ] No
Are the officials responsive to the need/ problems of the community?
[ ] Yes [ ] No
Do the barangay tanods watch over the safely of the community?
[ ] Yes [ ] No
Institution present:
[ ] Police station [ ] Hospital [ ] Health center
[ ] Recreational facilities [ ] Fire station
