Survey Form

I. Diocese of San Carlos
San Carlos City, Negros Occidental

FAMILY SURVEY FORM
I. Personal and Family Information
Name of Respondent (household):________________________________________
Address:_____________________________________________________________

Family Composition:
Name of family Age Sex Civil Religion Relation to Educa- Occu- Skills
Mmbers Status respondent tion pation














_______________Nuclear -______Extended

II. Income and Expenditure
1. Main source of income:_____________________________________________
Other sources of income:____________________________________________

2. How much is your family income? ______________daily_____________monthly
Is your income sufficient?___________
Insufficient?__________

3. How much do you spend for your food? __________daily____________monthly
How much do you spend for your clothing?________________________monthly
And others?__________________________


III. Housing Conditions
1. Do you own this house?
[ ] Yes [ ] No
1.1 If NO, is it…?
[ ] free [ ] common property
[ ] rented [ ] Others, specify________________________
[ ] owned by a relative

1.2 Do you still own other houses?
[ ] yes [ ] No

2. What is the area of the house? _______________________sq. m

3. How many rooms? _____________________________rooms/s
4. NOTE: JUST OBSERVE. ASK ONLY WHEN NECESSARY. What are the construction materials of the house?
4.1 roofing _______________________________________________
4.2 walling:_______________________________________________
4.3 flooring:_______________________________________________

5. What is your lighting facility?
[ ] electricity
[ ] kerosene lamp
[ ] petromax
[ ] others, please specify:____________________________________
_______________________________________


NOTE: ASK ONLY WHEN NECESSARY
WHAT ARE THE APPLIANCES AT HOME?
[ ] tables [ ] petromax
[ ] chair [ ] clay/stone stove
[ ] aparador [ ] motorcycle
[ ] sala set [ ] stone grinder
[ ] radio [ ] sewing machine
[ ] television [ ] electric stove
[ ] stereo phono [ ] others: please specify_________________

IV. Health and Sanitation
1. Is there any Health center in your area?
[ ] yes [ ] no
2. If yes, how often do you go to the Health Center?
_________every week
_________once a month
_________very seldom
_________never, why?____________________________________________

3. Have you undergone training on health and sanitation/ child care?
[ ] yes [ ] no

4. Toilet facilities
4.1 Do you have your own toilet? [ ] yes [ ] no
If yes, what type?
[ ] water sealed [ ] flushed
[ ] antipolo [ ] others, specify__________________

4.2 Are you using your toilet? [ ] yes [ ] no
If no, why?______________________________________________________

4.3 If you do not have a toilet where do you dispose your waste?


5. Garbage and Waste disposal
How do you dispose your garbage?
[ ] burning [ ] throw anywhere
[ ] burying [ ] others, specify
___________________________


How do you dispose your sewage?
[ ] feed to the pigs [ ] drainage
[ ] open drainage [ ] throw anywhere

What are the pests commonly found in your house?
[ ] rat [ ] mice
[ ] cockroaches [ ] flies
[ ] mosquito [ ] others, specify
___________________________


*NOTE: DON’T ASK; JUST OBSERVE:
General condition of surroundings:
Yes No
Presence of manure ________ __________
Presence of human excreta ________ __________
Presence of stray animals ________ __________
Stagnant water visible ________ __________
Others, specify ________ __________

6. Water supply
6.1 Where do you get your water for drinking/ washing?
Drinking washing/bathing
Faucet _________ ______________
Artesian well _________- ______________
Well __________ ______________
Spring __________ ______________
River __________ ______________
Others, specify __________ ______________

6.2 Where do you place/ store your drinking water?
[ ] earthen jar [ ] bamboo poles
[ ] bottles [ ] others, specify
[ ] plastic container __________________

6.3 Is drinking water container covered?
[ ] yes [ ] no

7. Diseases/ Illness
7.1 What is the common disease/ illness suffered by adult?
[ ] pneumonia [ ] gastro enteritis
[ ] tuberculosis [ ] malaria
[ ] bronchitis [ ] others, specify
[ ] tetanus ______________________

7.2 What is the common disease/ illness suffered by children?
[ ] pneumonia [ ] gastro-enteritis
[ ] tuberculosis [ ] malnutrition
[ ] bronchitis [ ] measles
[ ] tetanus [ ] others, please specify
_____________________
V. Leisure time
1. How much leisure time do you have (in hours/ day/ week)?
2. How do you spend your leisure time?____________________________________________________

VI. Values
1. Is there any chapel/ church in the area?
[ ] yes [ ] no [ ] I don’t know
2. Are you a member of any religious community-based orgamnization?
[ ] yes [ ] no [ ] I don’t know
3. How frequent do you attend religious rites, social or cultural affairs?
__________________________________________________________
4. Are there any government/ non-government projects/ programs in your place?
[ ] yes [ ]no [ ] I don’t know

5. What are they? _________________________________________________
6. Do you support these GO/NGO projects/ programs?
[ ] yes [ ] no [ ] I don’t know

7. How?_________________________________________________________

VII. Community Development
1. What are the existing organizations in the community?
Name of Org. Position Objectives Attending meeting If no, why
Of the Org. Yes No
-----------------------------------------------------------------------------------------------------------------







2. What are the projects of the organization?
Project Status of the project Involvement to the project
Active, inactive, somewhat inactive











3. Are your officers functional?
[ ] yes [ ] No Why?_________________________________

4. What are your activities in the organization?
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. In your opinion, do you have friends in the community?
[ ] many [ ] few [ ] moderate


6. Name 5 persons who are potential leaders in your community
Name Reasons for choosing
_______________________ ____________________________________
_______________________ ____________________________________
_______________________ ____________________________________
_______________________ ____________________________________
_______________________ ____________________________________

VIII. Needs/ Aspirations/ Projects
1. What are your dreams and aspirations in life?
Self:


Family:


Community:




2. What are the five most urgent needs or problems at present affecting your family and the barangay?
Family Barangay
____________________________ ______________________________
____________________________ ______________________________
____________________________ ______________________________
____________________________ ______________________________
____________________________ ______________________________

3. How do you describe your life condition five (5) years ago?
[ ] easy and things are abundant
[ ] very difficult
[ ] somewhat difficult
[ ] no idea

4. How do you describe your present life condition?
[ ] easy and things are abundant
[ ] very difficult
[ ] somewhat difficult
[ ] no idea

5. How do you describe your life in the next five (5) years?
[ ] easy and things are abundant
[ ] very difficult
[ ] somewhat difficult
[ ] no idea

IX. Mobility and Project Assessment

1. How long have you been here in this community?________________________


2. Is there any plan for your relocation?
[ ] yes [ ] no

2.1 If yes, who is going to relocate your family?
Government________________
On your own________________
Others, specify______________
Where_________________________________________

2.2 If no, how long are you going to stay here?___________________

3. If given some programs/projects, what kind of program do you want?
Livelihood Projects:

Skills Training:


Others:



4. If your children will have tutorial classes in the catholic school, are you willing to send them to school?
[ ] yes [ ] no
If no, why?































X. Interview Evaluation
(This is to be accomplished after the interview is completed. In filling out the blanks, you should not ask your respondents.)

1. How do you rate the attitude of your respondent toward the interview?
2. How do you rate the intelligence of your respondent?
3. Were there other people present during the interview?
3.1 If yes, were they
3.2 If all are adults or mixed, did other adults help your respondents answer the questions?
3.3 If yes, how frequent?



Conducted by:


Interviewer:___________________________
Date:___________________________