FAR EASTERN UNIVERSITY Institute of Nursing Community Health Survey Tool Head of the Family:_____________________________ Control No.

__________ (kinikilalang puno ng pamilya) Complete Address: __________________________________________ No. of Family/famil ies :___________ (Tirahan) (Bilang ng Pamilya) Length of Residency:_________________________________________ Surveyed by :_____ _______________________ (Tagal ng paninirahan sa lugar) (Pangalan ng Nag-survey) Place of Origin: _________________________________ Date :____________________ (Lugar na pinagmulan) (Petsa) Ethnic Background: ______________________________ (Etnikong grupo na kinabibilangan) Primary Dialect Spoken: __________________________ (Pangunahing Dialektong ginagamit) COMMUNITY AS A PEOPLE Family Structure, Characteristics and Dynamics No. Name of Relationship Education (Edukasyon) Occupation (Hanap Buhay) (Blg.) Household Member(s) (Pangalan ng myembro ng pamilya) to the head of the family (kaugnayan sa puno ng pamilya) Sex (Kasarian) Date of Birth (mo., day, yr.) (kapanganakan) Age (Edad) Civil Status (Estado Sibil) Religion (relihi -yon) Highest Educational Attainment Pinaka-mataas na Antas ng Edukasyong Educational Status (Antas ng

Edukasyon) Place (Lugar) Type (Uri) Occupational Status (Kalagayan ng Trabaho) natapos LEGEND: M male S Single C- Catholic EG Elementary Graduate NF No Formal Educatio n E Employed F - female M Married P Protestant EU Elementary Undergrad. PS Presently Studying U Unemployed W Widowed SA 7th Day Adventist HG High School Grad SS Stopped Studying CL Common Law INC Iglesia ni Cristo HU - High School Undergrad. C College Grad Sep Separated JW Jehova s Witness CU College undergrad V Vocational

COMMUNITY AS A SOCIAL SYSTEM A. Economic Aspect 13. Combined Monthly family income (Buwanang kita ng pamilya) 18. Community Program (Ano ang mga alam na programa sa komunidad) ( ) P1,000 and below ( ) P10,001 P15,000 ( ) P25,001 P30,000 ( ) P1,001 P5,000 ( ) P15,001 P20,000 ( ) P30,001 and above ____ aware _____ una ware ( ) P5,001 P10,000 ( ) P20,001 P25,000 ( ) peace and order ( ) fumigation ( ) curfew 14. Other sources of Income (livelihood) ( ) tapat ko linis ko ( ) sportfest ( ) others, pls. specify ______________ (Mayroon pa bang ibang pinagkukunan ng kabuhayan?) ( ) Yes ( ) No 19. Predominant Organizations in the community If yes, what? (kung mayroon, ano ito?) (Kilalang samahan sa komunidad) ( ) sari-sari store ( ) poultry raising ( ) livestock raising ( ) craft making ( ) Others {pls. specify}________________ ( ) Barangay Council ( ) Sangguniang Kabataan ( ) Couples for Christ ( ) Seniors Citizens Club 14. Monthly family expenditure (Buwanang gastusin ng pamilya) ( ) other, pls. specify _________________________ ( ) P1,000 and below ( ) P10,001 P15,000 ( ) P25,001 P30,000 _____ member _____ non - member ( ) P1,001 P5,000 ( ) P15,001 P20,000 ( ) P30,001 and above

( ) P5,001 P10,000 ( ) P20,001 P25,000 20. Traditions celebrated/ observed in the community (Tradisyong idinaraos/ ipinagdiriwang sa komunidad) 15. Priority Expenditure, rank it 1 7 (1 is the highest; 7 is the lowest) ( ) Fiesta ( ) Holy Week ____ food (pagkain) ____ health (kalusugan) ( ) others, pls. specify ___________ ___________________ ____ house rental (upa sa bahay) ____ education (edukasyon) ____ electric bill (bayarin sa kuryente) ____ clothing (damit) C. Environmental Aspect ____ water bill (bayarin sa tubig) 21. Land Ownership (Pagmamay-ari ng lupang tinitirahan) 16. Resources allotted for health care . (Nakalaang pondo para sa kalusugan) ( ) owned ( ) rented ( ) lease to own ( ) re nt free ( ) Yes ( ) No 22. House Ownership (pagmamay-ari ng bahay na tinitirhan) If yes, from where? (kung oo, galing saan?) ( ) Health Insurance ( ) SSS/GSIS ( ) owned ( ) rented ( ) lease to own ( ) rent free

( ) Phil Health ( ) savings ( ) others, please specify ________________ 23. Type of Materials Used for house (Uri ng Materyales ng bahay) B. Political / Leadership Aspect ( ) light ( ) strong ( ) mixed ( ) makeshift (barong barong) 17. Recognized leaders in the community (unang taong kinukunsulta at kinikilalang pinuno ng komunidad) 24. Ventilation ( ) Barangay Officials ( ) religious leaders ( ) elders ( ) well ventilated ( ) fair ( ) poorly ventilated ( ) Non- government organizations ( ) others, pls. specify ____________ (require ment: opening 10% of floor area)

25. Lighting facilities 33. Storage of drinking water (Imbakan ng inuming tubig) ( ) electricity ( ) kerosene ( ) candles ( ) Jar (banga) ( ) plastic/glass conta iner ( ) others, pls. specify ___________________ ( ) bottles ( ) drum ( ) water tank ( ) water dispenser ____ adequate ____ inadequate _____ covered _____ uncovered 26. Excreta Disposal ( Uri ng Palikuran) 34. Method commonly used in sanitizing water (Paraang ginagamit upang mapanatiling malinis ang inuming tubig) ( ) pail system ( ) open pit privy ( ) flush type ( ) Antipolo type ( ) boiling (pagpapakulo) ( ) bored hole latrine ( ) closed pit privy ( ) filtration (pagsasala ( ) overhung latrine ( ) water sealed latrine ` ( ) sedimentation (pagpapalatak) ( ) others, pls. specify __________________________ 27. 35. ( ) ( ) ( ) 28. ( ) Ownership of Toilet Facility (pagmamay-ari ng palikuran) Domestic animals upkeep (dogs and cats only) private (sariling gamit) shared (may kahati sa gamit) public (gamit pambayan) Sewerage System in the community ( Uri ng kanal sa komunidad) blind drainage ( ) open drainage ( ) none

29. Condition ( kalagayan ng daloy ng tubig sa kanal) Kind Number Place kept Vaccination (Bakuna sa hayop) (Uri) (bilang) (pinaglalagyan ) With (mayroon) Without (wala) 36. ( ) ( ) ( ) Present of vectors and rodents (pagkakaroon ng peste sa bahay) free flowing stagnant ( ) flies (langaw) ( ) termites (anay) ( ) rats (daga) roaches (ipis) ( ) mosquitoes ( lamok)

30. Type of waste disposal used (Uri ng pagtatapon ng basura) ( ) others, pls. specify __________________________ ( ) animal feed ( ) composting 37. Presence of breeding sites of vectors ( pagka karoon ng lugar na ( ) open dumping ( ) burial pit pinamamahayan ng mga peste) ( ) burning ( ) garbage collection (DPS) ( ) others, pls. specify __________________________ ____ with ____ without if with, pls. specify location _______________________ 31. Container used for garbage 38. Ways of controlling vectors (Paraang ginagawa upang mapuksa ang mga ( ) garbage bag ( ) waste basket ( ) sack ( ) none peste sa bahay) ____ covered ____ uncovered ( ) fumigation (pag-papa-usok) ( ) insecticides ( pmatay insekto) 32. Source of drinking water (pinanggagalingan ng inuming tubig) ( ) fly traps ( ) mouse traps ( ) screens on doors and windows

( ) commercially prepared water ( ) deep well ( ) others, pls. specify _________ ____________________________ ( ) local water system ( ) rain water

( ) artesian well ( ) streams, rivers or spring D. Health Aspect 39. Community health programs (programang pangkalusugan) Aware Utilizes 43. Medi cations taken during illness (Gamot na iniinom) (Alam) (nagkukunsulta) ( ) Free consultation (libreng konsulta) ______ _______ ( ) prescribed ( ) herba l ( ) over the counter ( ) Immunization (libreng Bakuna) ______ _______ ( ) others ( Pls. Specify) ____ _________________ ( ) Family Planning (Programa sa pagpapaplano ng pamilya) ______ _______ ( ) Pre-natal Check up (programa para sa buntis) ______ _______ ( ) well-baby clinic (konsulta para sa mga sanggol at bata) ______ _______ ( ) Others (Pls. Specify) ____________________________ ______ _______ 44. Method of Family Planning (Pagpaplano ng pamilya) Name Age Acceptor NonAcceptor 40. Food usually eaten. (Madalas ng kinakain) A. Natural ( ) Fish ( ) Meat ( ) Vegetable ( ) Mixed ( ) rhythm ( ) cervical mucus method ( ) withdrawal 41. Food storage practices. (Pangangalaga sa pagkain) ( ) Basal body temperature ( ) others (specify) ____________ ( ) refrigerator ( ) table ( ) basket ( ) others B. Artificial contraceptives ____ covered ____Uncovered ______________ ( ) condoms ( ) IUD ( ) pills ( ) othe rs __________ 42. First person consulted in times of illness (Unang taong kinukunsulta tuwing C. Permanent may nagkakasakit) ( ) vasectomy ( ) doctor ( ) albularyo ( ) midwife ( ) relatives ( ) tubal ligation ( ) nurse ( ) faith healer ( ) family ( ) BHW ( ) hilot ( ) others (pls. specify)______________

 For items 45 48: Answer only if applicable o 46 and 47 If there are children 0 12 months in the family o 48 if there are children 0 83 months (0 7 yrs) in the family o 46 if there is a pregnant member of the family 45. Infant Feeding Program ( ) Breast Milk ( ) Commercially Prepared Milk ( ) Mixed Commercially Prepared:: _____ Condensed Milk _____ Evaporated Milk _____ Powdered Milk _____ Others (please specify) ________________ 46. Maternal Care (Pangangalaga sa mga buntis) Name (Panganlan) No. of Pregnanc y Age of Gestation (Bilang ng buwan ng pagbubuntis) Expected Date of Delivery (Inaasahang petsa ng panganganak) PreNatal Check - Up Tetanus Toxoid Immunization with without with without 47. Immunization Status of Target Age Group (0 12 months) Name Age in Mos. BCG DPT OPV Hepatitis B AMV Remarks 1 2 3 1 2 3 1 2 3 incomplete complete Fully Immunized

48. Nutritional Status for Children (0 Name (Pangalan) Date of Weighing (Petsa ng Pagtimbang) Date of Birth (Kapanganakan) Age ( in months) (Edad) Weight (Bigat) Remarks 49. Morbidity Name (Pangalan) Age (Edad) Sex (Bigat) Intervention (Medication) With Without -END

83 months)