FAMILY AND COMMUNITY PROFILE I. GENERAL INFORMATION A.

Family Background Head of the family: Address: Birthday: Educational Attainment: Occupational: _________________ Religion: Type of Family: (specify) _______ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________ Age: ___________________ ___________________________________________________________________ ___________________________________________ Salary: ___________________________________________________________________ Traditional Extended Others

B. How many members of the family are staying in the house? ____________ Name Relation to the head Birthd ay Ag e Sex Education Occupatio n Salary (Monthl y) Remark s

C. For children 0-5 years old Type of Feeding (breastfeeding, bottle feeding, mixed supplementary Immunization (fully imm.; incomplete; defaulter 0-1 yr. old)

Name

Ag e

Se x

Weig ht

Nut. Status

Educatio nal Level

D. Health Condition for the Past Year (only if with deviation from normal) Name of the Sick Member Ailment Date of Occurrence Treatment a. procedure b. medications Present Condition

E. Deceased Family Member for the Past Year (if applicable) Name of Deceased Cause of Death Date of Died

F. How many member/s of the family is/are: 1. smoking? _______________________________________________________ 2. drinking alcoholic beverages? _______________________________________ 3. using gambling as form of recreation? ________________________________ II. HEALTH AND ENVIRONMENTAL STATUS A. Housing 1. Type bungalow two-storey nipa hut others (specify ____________ 3. Number of windows per room 1 2 3 or more 5. Is your house well lighted? Yes No B. Water 2. Rooms 1 2 3 or more

4. Ownership rented owned others (specify) ____________ Others (specify) _____________

1. Supply/Source NAWASA

deep well

water refilling

public

2. Type of storage container Plastic Clay jar Tin can others (specify) _____________ C. Excreta disposal Toilet Facility Yes Water sealed Open pit flush others (specify) ____________ D. Garbage disposal 1. Do you segregate waste at home? 2. Method of disposal

No ballot system directly to drainage others (specify) _____________ Yes No

open pit burning dumping garbage collector others (specify) _________

3. How many times is the garbage collected? everyday twice a week every other day others (specify) once a week _____________ 4. Approximate amount of garbage generated per day? kilogram 2 kilograms 1 kilogram 3 kilograms or more E. Food establishment (if any within community) 1. Type of food establishment sari-sari store ambulant vendor carinderia F. Drainage System Condition: flowing clogged Open

talipapa others (specify) _____________ covered well-maintained stagnant none

G. How many animals are raised at home? ________ 1. Type/kind of animals raised (specify) ____________________________ 2. Are these for sale family consumption pets others (specify) _______________ 3. Where does the solid wastes of animals go? drainage soil river others (specify) _______________ III. NATURAL RESOURCES IN THE COMMUNITY 1. What are the natural resources observed in the community? Rice fields (bukid) Forestry

River/Lake Others (specify)

Agro-forestry _____________

2. Are you dependent for living on the natural resources found in the community? Yes No 3. resources? Yes No If yes, please specify ________________________________________ IV. COMMUNITY SERVICES 1. Sources of community services National level Municipal level Barangay level Religious organization NGO others (specify) _____________ Is there any livelihood program by the community out of these natural

2. What services are they giving to the community? Health/physical Social aspect Environmental sanitation Spiritual aspect Others (specify) _____________ 3. Are you involved in some civic activities in your community? No a) To what organization do _________________________________________ b) What is your __________________________________________________ c) Position in the ________________________________________ you belong? participation? community/organization Yes

4. Are there members of the family involved in some civic activities? _______________________