Community Health Survey Report

Municipality:
1) Name of the Head of the family

2) Address

3) Family members details Name Relationship

1)
2)
3)
4)
5)
6)
4) House Own/ Rent

5) Roof Thatched/ Tiled/ Concrete

6) No. of the Rooms

7) Ventilation Adequate/ Inadequate

8) Latrine Water seal/ Open field

9) Usage of latrine Yes / No

10) Drainage Open/ Closed

11) Disposal of waste Pit/ Burning/ Dumping

12) Electrical Supply Yes / No

13) Water Supply Municipality / other source ( )

14)
Monthly Family Income (Rs.)

15) Remark

HOD of Community Health Nursing: Student:

 PRINCIPAL

Door no:

Family Religion:
no:

Street Corporation/
name: municipality/
Town
Panchayat/
Panchayat

Urban
/Rural :

Name of
Locality