HOUSEHOLD SURVEY FORM

INSTRUCTION: Please provide the answers to the questions below. No questions must be left unanswered. For
question/s which is/are not applicable, kindly write N/A.

I. FAMILY MEMBERS AND CHARACTERISTICS

A. Basic Information About HEAD OF THE FAMILY

Name: Josephine Macario Birthdate: November 15, 1995 Age: 26 Sex: F

Highest Educational Attainment: Highschool Occupation: Unemployed Monthly Income: 3,000-5,000

Civil Status:

Married  Legally □ Common Law

Widowed
Separated
Single

Employment Status:

Permanent □ Private □ Public

Temporary  Casual □ Contractual
Self-employed
Unemployed

B. Other Family Members:

No. of children in the household:
Total: 1 Male: 1 Female: _____
No. of other dependents in the household:
Total: 1 Male: 1 Female: _____

RELATION HIGHEST
CIVIL MONTHLY
NAME TO HEAD OF AGE SEX EDUCATIONAL OCCUPATION
STATUS INCOME
THE FAMILY ATTAINMENT
Wilbert Macario Husband 28 M Married College Police 30,000
degree
Joseph John “Jj” Son 10 M
Macario months

**NOTE:
 For children ages 3-5, indicate under educational attainment column whether attending
daycare or not.
 For children ages 6-16, state whether currently studying or not under occupation.

II. SOCIO-ECONOMIC AND CULTURAL CHARACTERISTICS

A. Religion: (please specify) Anglican
B. Primary dialect/ language spoken at home: Kan-kana ey
C. Income:
C.1 Estimated average family income per month (total family income: from A and B, please
check)
Above 50,000______ P30,001-35,000 P10,000-15,000 ____
P45,001–50,000 ____ P25,001-30,000 P5,001-10,000 ____
P40,001-45,000 ____ P20,001-25,000____ _ P1,001-5,000 _____
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 P35,001-40,000_____ P15,001-20,000_____ P1,000 & below____

C.2 Primary source of Livelihood:

Farming _____ Owned: ____ Tenanted: ____
Laborer: _____ Carpentry: _____
Fishing: ______ Peddling: _____
Employee:
Small Industries: (sari sari store, carenderia, etc. )_____
Others (specify): Livestock and hog raising

C.3 Food Production Engaged in (may check more than one): yes, ____no
(if yes, please answer below)
RESOURCES FAMILY CONSUMPTION SELLING BOTH
Vegetable gardening
Piggery
Poultry
Fruit trees
Others: (pleases specify)
__________________

__________________

D. Real Property
D.1 Type of property owned:
___ Farmland (rice, coconut, others)
___ Residential Lot
Residential lot with house
___ Commercial Lot with building
___ Others (Specify)
D.2 Housing:
a. ownership: owned ____ rented ___ shared
b. type of construction:
___ light
medium (wooden floors/walls with nipa roof)
heavy (dominantly concrete/ hardwood with galvanized sheets)
D.3 Facilities:
a. Type of appliances owned:
radio ___ CD Electric Fan
___ cassette ___ DVD refrigerator
TV Gas burner ___ Computer Set
___ Laptop ___ Others: (specify) Perculator

b. Vehicles owned: (for people and/or goods)

___ car ___ tricycle others (specify)
___ private jeep motorcycle
___ truck ___ kuliglig

c. Utilities
Electrical connection

Telephone / cellphone

D.4 All family members with basic clothing of at least 3 sets of external and internal clothing:
yes ___ no

D.5 Family Consumption:

Family Food Consumption Adequate (please check) Inadequate (please check)

Eat 4 times or more
Eat 3 times a day
Eat twice a day
Eat once a day

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 E. Decision making pattern (please check the appropriate column, you may check more than one)
DECISION AREA FATHER MOTHER CHILDREN SINGLE
Family Expenses .
Health
Education
Participation in Community activities

III. HEALTH STATUS AND PRACTICES

A. Food, nutrition and Immunization Status (children 0-72 months old)

a.1 Infants exclusively breastfed for four months:

Name of Child Exclusively breastfed for 6 months If NO, state reason

YES NO
Joseph John Macario

a.2 Supplementary feeding: (children 0-72 months old)

Name of child Supplementary feeding If yes, what were the types of food given? Age started
Yes No
Joseph John Macario Cerelac, fruits, mashed vegetables 6 months

a.3.1 Nutritional Status of children 0-72 months

Name Birthdate Date of Weight Status Height Status

Weighing
Joseph John Macario December October 2, 7 kls N/a
8, 2020 2021

a.3.2 Immunization Status (Children 0-12 months old)

Name Age in Types of Immunization

months BCG OPV1 OPV2 OPV3 PCV1 PCV2 PCV3 IPV MMR Penta MMR Status
Joseph 10 Complete
John months
Macario

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 mothers given at least 2 doses of Tetanus toxoid:
yes ___ no
3. Pregnant mother given prenatal care: yes ___ no
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 3.1 First visit made in the first trimester yes ___ no
3.2 Had at least 1 visit per trimester yes ___ no
3.3 Total number of pre-natal visit: 7

4. Postnatal visit within 4-6 weeks postpartum: yes ___ no

5. Delivery handled by trained health personnel: yes ___ no
If yes, specify: ___ trained hilot
___ RHM
___ Nurse
Physician
If no, who handled the delivery? (specify) _______________________

C. Family Planning (To be answered by MCRA’s in the household):

1. Couples with access to family planning services: yes no
2. Couples practicing family planning: yes no
If yes, specify method: Calendar Method
If no, state reason:

D. Morbidity (Past 1 year, please counter-check with secondary data)

1. Any of the children below 6 years old had more than 1 diarrheal episodes: ____ yes no
2. Other illnesses experienced by family members:

Type of Illness Age Sex Health worker attended Treatment used

Cough and Cold 28 M Physician Medicine
Fever 11 M N/A Medicine, Traditional
months remedies

E. Mortality (Past 1 year, please counter-check with secondary data)

1. With deaths in the family due to preventable diseases (past 1 year): ____ yes no
2. Causes: N/A

Type of Illness Age Sex Health worker attended Treatment used

F. Health Seeking behavior and Utilization of Health Services:

1. Family member with Phil health:

Name Status Remarks

Josephine Macario Voluntary N/A
Wilbert Macario Member N/A

2. Family members avail of health services: yes ___ no

3. With solo parent availing health services: ___ yes no
4. Delays in accessing health care
a. Reasons in delaying decisions to seek health care:
___ Failure to recognize danger signs
___ lack of money to pay expenses
No available person to take care of the children and home
___ Lack of companion in going to the health facility
others; specify Lockdown, Covid-19 threat
b. Reasons for reaching appropriate care in a health facility
Distance of home to a health facility
___ Lack of transportation
others: specify Covid-19 threat
c. Delays in Receiving appropriate care in a facility
Shortages of supplied and basic supplement in a health facility

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 ___ lack of skilled health personnel in the hospital
___ Poor skills of health care providers
___ Others: specify ________________________________
5. Health services most frequently availed of: (please rank)
2 RHU 1 Private Clinic
4 BHS 3 Hospital private ___ public
6. Health worker preferences during illness (rank using numbers according to who is seen first)
4 Medicine man 2 Nurse others: specify ________________
3 Midwife 1 Doctor
7. Health interventions done during illness (Rank using numbers according to who is seen first):
1 Self-Medication: Specify Increasing water intake, rest
4 Consult medicine man (Albularyo)
2 Consult RHM
4 Consult Nurse
3 Bring Patient immediately to the hospital
___ Others: specify ________________________

IV. ENVIRONMENTAL CONDITION

a. Safe water
1. Access to safe drinking water within 250 meters or 10 minutes’ walk from their home:
yes ___ no
2. Water source (please check):
Level 1: ____ Protected well
____ Developed spring
Level 2: Piped distribution network and communal faucet
Level 3: ____ Waterworks system for individual households
Others: ____ Shallow dug well
____ Unprotected spring
____ Others: (Specify) ______________________________
3. Method of water storage: ____ open container covered container
4. Method of water treatment: ____ chlorination boiling ____ no treatment

b. Method of Excreta Disposal:

Types: WST owned:

functional ____ non-functional

____ WST shared:
___ functional ____ non-functional
____ without, specify: _________________________________

c. Method of Domestic Water waste Disposal: ___ Blind drainage Open Drainage

d. Method of Garbage collection and disposal (common HH practices):

Collection: open receptacle ___ none
____ covered receptacle

Disposal: composting ____ burying

____ burning ____ open dumping
____ riverside dumping ____ others

e. Method of animal management:

Kind of animals: specify: Pigs and chickens ___domestic agricultural
_____ tied fenced astray
_____ both ____ no animals
f. Food Storage:
____ cabinet ___ covered plates ___ others: specify
covered basket refrigerator ____________________

V. PEOPLES PARTICIPATION IN COMMUNITY DEVELOPMENT:

1. Family members involved in at least one legitimate people’s organization / community
development: ____ yes no
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 2. Number of family members involved:N/A
3. Name in organization involved in (specify): N/A
4. Awareness in existing organizations:
List name of organizations known to be respondent even if not a member: Church Ministries
5. Participation in other community activities / projects:
List projects / activities participated in: Church Volunteer

VI. COMMUNITY RESOURCES, NEEDS AND PROBLEMS:

A. MANPOWER:

Recognized leaders / Community members that can be tapped in the implementation of

community projects:
NAME POSITION SPECIALIZATION
Franklin Odsey Mayor

B. MATERIAL

Identify available material resources in the community that can be used for community projects,
specify:
Spare woods

C. Needs and Problems:

Based on your perception, identify at least 3 most important problems and possible solution that
can affect the health and development of your community”

PROBLEMS RECOMMENDATIONS
Lack of Health Care Provider Travel to reach a primary care provider may be
costly and burdensome for patients living in
remote rural areas especially in this time of a
pandemic. There should be a routine weekly
monitoring of health care providers in the rural
areas that lacks health access.
Vaccine Hesitancy Immunization scares have hampered a number
of recent immunization campaigns. To further
eradicate this, the DOH must provide efficient
information dissemination on the benefits of
being vaccinated.
Delay or Avoidance of Medical Service Provide communities with adequate
information on seeking medical help. Inform
them about the specific organization to be
contacted in case of an emergency.

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