Bachelor of Science in Social Work – Community Innovations and Development Solutions

Community Household Survey Questionnaire

This survey is part of the initiatives involved under the SPAMAST Social Work Program, Bachelor of Science
in Social Work- Community Innovations and Development Solutions. This project is currently with active
partnership together with the Barangay. The details of this survey aim to gather data in relation to situation at the
household and community level to consolidate relevant information that would be supplementary to succeeding
interventions of the project within the barangay and the community.

Consent:
I (optional) ______________________, ___ (age) consent to the gathering of data in relation to my household/ and
community situation.
__________________________
Name and Signature of Respondent
Date of interview: _____________

I. HOUSEHOLD INFORMATION

Name of Respondent: Age:

Relationship to household Gender Number of Family Educational attainment of household
head:  Male Members: head
 Household head  Female  Below 3  Elementary level
 Spouse  LGBTQ+ members  Elementary graduate
 Child  3-5 members  High school level
 Parent Civil status  6-8 members  High school graduate
Gender  Single  9-10 members  College Level
 Male  Married  Above 10  College Graduate
 Female  Separated members  Post-graduate
 LGBTQ+  Live-in  Vocational course graduate
Civil status  Widowed/er  Others: ___________
 Single
 Married
 Separated
 Live-in
 Widowed/er
Religion: Ethnicity Language spoken
 Roman catholic  Bisaya  Bisaya
 Islam  Tagakaulo  Tagalog
 Christian  B’laan  English
 Protestant  Manobo  Local dialect
 Others: ______________________  Others: _____________

Is there a pregnant woman within the household? Is there a senior citizen within Is there a PWD within the
 Yes the household? household?
 No  Yes
 Yes  No
Are there any child ages 0-5 within the household?  No
 Yes What is his/her physical
 No condition?
________________________
 II. HOUSING CONDITIONS
Source of drinking water Source of electricity Type of toilet facility
 Owned meter  Owned meter  Water sealed
 Buy  Connect with neighbor  Close pit or private
 others  Solar panel antipolo
 others  Open pit
 No toilet
Do you own your house? Do you own the lot where you live?
 Yes  Yes
 No  No

If no, do you If no, do you

 Rent  Rent
 Live at parent/relative’s  Live at parent/relative’s lot for
house for free free

III. ECONOMIC CONDITIONS

Main source of income: Household head occupation: Gadgets and/or appliances owned:
 Employment ________________________  Television
o Public  Radio/component
agency/government Employment status:  Computer/laptop
o Private company  Regular  Cellphone
 Own business  Contractual  Rice cooker
 Pension  Seasonal  Electric stove
 Allowance  On-call job  Aircon
 Others: __________________  Electric fan
Monthly family income: Household head monthly income:  Washing machine
_____________________________ _____________________  Refrigerator
Are there credit facilities within the If yes, what are these credit  Others: ___________
community? facilities
 Yes  Individual lender
 No  ASA
 Cardbank
 Others: _______________
IV. HEALTH CONDITION
Common ailments in the family Serious ailments in the family Do you observe family Do you observe regular
 Skin disease  Pneumonia planning? check-ups?
 Cough  Cancer Yes Yes
 Common colds  Tuberculosis No No
 Flu  Heart ailment Only when necessary
 Diarrhea  Hypertension Family planning methods
 Others: _________  Asthma  Calendar
 Urinary tract infection method
Is there history of serious  Arthritis  Pills
ailment/sickness in the family?  Kidney problem  IUD
 Yes  Others:  Injectables
 No  ___________________  Others:
______________
Where is the nearest health Does the family avail services If yes, what services were availed?
facility that the family goes to? from the health center?  Free medicine
 Yes  Vaccine for infant
 No  Pre-natal
  Family planning
 Free check-up for
o Children senior citizen
o Pregnant

V. POLITICAL CONDITIONS IN THE AREA

Who are key officials in the community? Is there any non-elected community leader/s of which
people go to for their concerns in the community?

Is the community relatively peaceful and safe? What are peace and order issues encountered in the
 Yes community?
 No  Theft/burglary
 Not sure  Public disturbance
 Riot
Is there a police/BPAT outpost?  Gangs
 Yes  Drug use
  Marital dispute
 No  Illegal fishing

Does the barangay/purok tanod conduct roving? Others: ________________

 Yes
 No
If yes, how often? __________________

VI. SOCIO-CULTURAL SITUATION

Are there existing people’s organization within the What religious place for worship are existing within the
community? community?
 Yes  GKK
 No  Christian church
If yes, identify if the following POs/CSOs exist.  Mosque
 Women’s association  Others: _______________________________
 Homeowners’ association
 Youth association What are facilities present within the community?
 Senior Citizen association  Barangay hall
 Others: __________________________________  Health center
 Basketball court
 Public toilet
 Public market
 Pisonet services
 Day care centers
 Elementary school
 High school
 Others: _______________________

What are common means of transportation within the What are skills that are common to community
community? members?
 Public vehicle  Handicraft
 Private vehicle  Woodworks/ furniture making
 Others: ______________________  Food processing
 Others: _______________________
 vii. ENVIRONMENTAL SITUATION WITHIN THE COMMUNITY
Is proper waste disposal observed within the community? Is there a MRF within the community?
 Yes  Yes
 No  No

Is there a schedule for garbage collection within the What are hazards present within the community?
community?  Fire
 Yes  Strong winds
 No  Monsoon winds
 Flooding
If yes, how often  Mosquito borne diseases
 Weekly  Others:
 Twice a month _________________________________
 Others: ___________

VIII. PRESSING ISSUES WITHIN THE COMMUNITY

What are existing issues/concerns do you think are present within the community?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

What can you recommend to address these issues and concerns?

______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________

Interviewed by:

___________________________________
Signature above printed name of interviewer