SDBORJA22 (^^,)v
FAR EASTERN UNIVERSITY
Institute of Nursing
Associate in Health Science Education
SY 2007-2008
Community Health Survey Tool
Control Numbers: Date of Tallying:
Batch No.:
A. Length of Residency
Tally
Total
0-6 months
7 months and above
B.1 Place of Origin
Tally
Total
Cavite
B.2 Place of Origin
Tally
Total
Luzon
Visayas
Mindanao
C. Ethnic Background
Tally
Total
Tagalog
D. Primary Dialect Spoken
Tally
Total
Tagalog
F. No. of Families
Tally
Total
1
2
3
G. No. of family members
Tally
Total
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16 and above
I.1 Age
Tally(Male)
Total
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75 and above
I.2 Age
Tally(Female)
Total
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75 and above
J. Civil Status
Tally
(0-14 yrs. old not included)
Total
Single
Married
Widowed
Common Law
Separated
K. Religion
Tally
Total
Catholic
Protestant
7th day Adventist
Iglesia ni Cristo
Jehovah’s Witness
Others
L. Highest Educational Attainment
Tally
Total
EG
EU
HG
HU
CU
C
V
DH
M. Educational Status
Tally
Total
NF
PS
SS
N. Place of Occupation
Tally
Total
WC
OC
O. Type of Occupation
Tally
Total
Buy and Sell
P. Occupational Status
Tally
Total
E
U
SE
UE
Q.Family Income each
Tally
Total
P1,000 and below
P1,001 – P5,000
P5,001 – P10,000
P10, 001-
P 15,000
P15, 001-
P 20,000
P 20, 001-
P 25,000
P25, 001-
P 30,000
P30, 001 and above
1. Combined Family Income
Tally
Total
P1,000 and below
P1,001 – P5,000
P5,001 – P10,000
P10, 001-
P 15,000
P15, 001-
P 20,000
P 20, 001-
P 25,000
P25, 001-
P 30,000
P30, 001 and above
2.1 Other sources of income
Tally
Total
Yes
No
2.2 if yes…
Tally
Total
Sari-sari store
Craft Making
Poultry raising
Livestock raising
Others
3. Monthly Family Expenditure
Tally
Total
P1,000 and below
P1,001 – P5,000
P5,001 – P10,000
P10, 001-
P 15,000
P15, 001-
P 20,000
P 20, 001-
P 25,000
P25, 001-
P 30,000
P30, 001 and above
4. Priority Expenditure
Tally
Total
Food 1
Food 2
Food 3
Food 4
Food 5
Food 6
Food 7
Health 1
Health 2
Health 3
Health 4
Health 5
Health 6
Health 7
HR 1
HR 2
HR 3
HR 4
HR 5
HR 6
HR 7
Educ 1
Educ 2
Educ 3
Educ 4
Educ 5
Educ 6
Educ 7
Elec Bill 1
Elec Bill 2
Elec Bill 3
Elec Bill 4
Elec Bill 5
Elec Bill 6
Elec Bill 7
Water Bill 1
Water Bill 2
Water Bill 3
Water Bill 4
Water Bill 5
Water Bill 6
Water Bill 7
Clothing 1
Clothing 2
Clothing 3
Clothing 4
Clothing 5
Clothing 6
Clothing 7
5. Resources allotted health care
Tally
Total
Yes
No
5.1 if yes…
Tally
Total
Health Insurance
GSIS, SSS
Phil Health
Savings
Others
6. Recognized leaders in the community
Tally
Total
Brgy. Officials
Elders
Religious Leaders
NGO
Others
7. Community Program
Tally
Total
Peace and Order
Sportfest
Tapat ko linis ko
Curfew
Fumigation
Operation Tule
Others
8. Predominant Organization
Tally
Total
Brgy. Council Member
Brgy. Council non -member
SK member
SK non-member
CFC member
CFC non- member
Seniors’ Citezen Club member
Seniors’ Citezen Club non-member
Rotary Club member
Rotary Club non-member
Others, member
Others, non-member
9. Traditions observed
Tally
Total
Fiesta
New Year
Christmas
Holy Week
Thanksgiving
All Saint’s Day
Others
10. Land
Tally
Total
Owned
Rented
Lease to Own
Rent free
11. House Ownership
Tally
Total
Owned
Rented
Lease to own
Rent free
12. Type of material for house
Tally
Total
Light
Strong
Mixed
Makeshift
13. Ventilation
Tally
Total
Well Ventilated
Fair
Poorly Ventilated
14. Lighting Facilities
Tally
Total
Electricity
Kerosene
Candles
Others
15. Excreta Disposal
Tally
Total
Pail System
Flush type
Bored hole lantrine
Overhung Lantrine
Open pit privy
Antipolo Type
Closed pit privy
Water sealed lantrine
16. Type of ownership
Tally
Total
Private
Shared
Public
17. Sanitary Condition
Tally
Total
Clean
Unclean
18. Sewerage System
Tally
Total
Blind drainage
Open drainage
none
19. Condition
Tally
Total
Free flowing
Stagnant
20. Segregating
Tally
Total
Yes
No
21. Type of waste disposal
Tally
Total
Animal Feeding
Composting
Open dumping
Burial pit
Burning
DPS
Others
22.1
Container use for garbage
Tally
Total
Garbage bag
Waste basket
Sack
None
22.2 Container
Tally
Total
Covered
Uncovered
23. Source of drinking water
Tally
Total
Local Water System
Rain water
Artesian Well
Streams, river, spring
Deep well
Commercially prepared water
24.1 Storage for drinking water
Tally
Total
Jar
Bottle
Plastic glass container
Water dispenser
Water tank
24. 2 Storage
Tally
Total
Covered
Uncovered
25. Methods commonly used for sanitizing water
Tally
Total
Boiling
Sedimentation
Filtration
Others
26. Source of sanitary water
Tally
Total
Local Water System
Rain water
Artesian Well
Streams, river, spring
Deep well
27.1 Storage for sanitary water
Tally
Total
Jar
Bottle
Plastic glass container
Water dispenser
Water tank
Drum
27. 2 Storage
Tally
Total
Covered
Uncovered
28.1 Domestic Animals (kind)
Tally
Total
Dog
Cat
28.2 Domestic Animals (number)
Tally
Total
Dog 1
Dog 2
Dog 3
Dog 4
Dog 5
Cat 1
Cat 2
Cat 3
Cat 4
Cat 5
28.3 Domestic Animals (place kept)
Tally
Total
28.4 Domestic Animals (Vaccination)
Tally
Total
With
Without
29.1 Presence of Vectors
Tally
Total
Flies
Roaches
Termites
Mosquitoes
Rats
Others
29.2.1 Breeding Site
Tally
(Flies)
Total
29.2.2 Breeding Site
Tally
(Roaches)
Total
29.2.3 Breeding Site
Tally
(Termites)
Total
29.2.4 Breeding Site
Tally
(Mosquitoes)
Total
29.2.5 Breeding Site
Tally
(Rats)
Total
29.2.1 Breeding Site
Tally
(Others)
Total
29.3.1
Ways of Controlling
Tally
(Flies)
Total
A
B
C
D
E
F
G
H
I
29.3.2
Ways of Controlling
Tally
(Roaches)
Total
A
B
C
D
E
F
G
H
I
29.3.3
Ways of Controlling
Tally
(Termites)
Total
A
B
C
D
E
F
G
H
I
29.3.4
Ways of Controlling
Tally
(Mosquitoes
Total
A
B
C
D
E
F
G
H
I
29.3.5
Ways of Controlling
Tally
(Rats)
Total
A
B
C
D
E
F
G
H
I
29.3.6
Ways of Controlling
Tally
(Others)
Total
A
B
C
D
E
F
G
H
I
30.1 Community Health Programs
Tally
(AWARE)
Total
Free Consultation
Immunization
Family Planning
Well baby clinic
Diarrhea Control
Cancer Control
Dental Care
Nutrition
Leprosy
TB
Sanitation
Others
30.1 Community Health Programs
Tally
(UNAWARE)
Total
Free Consultation
Immunization
Family Planning
Well baby clinic
Diarrhea Control
Cancer Control
Dental Care
Nutrition
Leprosy
TB
Sanitation
Others
30.3 Community Health Programs
Tally
(UTILIZES)
Total
Free Consultation
Immunization
Family Planning
Well baby clinic
Diarrhea Control
Cancer Control
Dental Care
Nutrition
Leprosy
TB
Sanitation
Others
30.4 Community Health Programs
Tally
(UTILIZES)
Total
Free Consultation
Immunization
Family Planning
Well baby clinic
Diarrhea Control
Cancer Control
Dental Care
Nutrition
Leprosy
TB
Sanitation
Others
31. 1 Health Practices
Tally
(PRACTICED)
Total
Use of hygienic product
Sleeps 6-8 hrs a day
Brushes teeth
Cuts the nails
Clean ears
Change clothes
Eats balanced diet
Regular exercise
Dental check-up
Medical check up
Recreational Relaxation Activities
31. 2 Health Practices
Tally
(Not PRACTICED)
Total
Use of hygienic product
Sleeps 6-8 hrs a day
Brushes teeth
Cuts the nails
Clean ears
Change clothes
Eats balanced diet
Regular exercise
Dental check-up
Medical check up
Recreational Relaxation Activities
32. Food Usually Eaten
Tally
Total
Fish
Meat
Rice
Vegetables
Fruits
Others
33.1 Food Storage practices
Tally
Total
Refrigerator
Table
Basket
Others
33.2 Food Storage Practices
Tally
Total
Covered
Uncovered
34. First person consulted in times of illness
Tally
Total
Doctor
Arbularyo
Midwife
Relatives
Nurse
Faith Healer
BHW
Hilot
Others
35.1 Medication during illness
Tally
Total
Drugs
Herbal
35.2 Medication during illness
Tally
Total
Prescribed
Self-prescribed
36.1 Methods of Family Planning
Tally
Total
Acceptor
Non-acceptor
User
Non-user
36.1 Methods of Family Planning
Tally
Total
NC
NR
NW
NB
AC
AI
AP
PV
PT
37.1 Infant Feeding Program
Tally
Total
Breast Milk
Formula
Am
Mixed
37.2 Formula Used
Tally
Total
Condensed Milk
Evaporated Milk
Coffee
Powdered Milk
Others
38.1
Maternal Care (No. of Pregnant woman in the family)
Tally
Total
1
2
3
4
5
38.2
Maternal Care (Prenatal Check-up)
Tally
Total
With
Without
38.3
Maternal Care (Tetanus Toxoid Immunization)
Tally
Total
With
Without
39.1
Immunization Status (No. of Infants in the family)
Tally
Total
1
2
3
4
5
39.2
Immunization Status (Remarks)
Tally
Total
Complete
Incomplete
Fully Immunized
40. 1 Nutritional Status (No. of Child)
Tally
Total
1
2
3
4
5
6
7
8
40. 1 Nutritional Status (Remarks)
Tally
Total
Underweight
Normal
Overweight
Obese
41. 1 Morbidity (No. of people of got ill within the year)
Tally
Total
1-3
4-6
7-9
10-12
13-15
41. 1 Morbidity (Intervention)
Tally
Total
With
Without
42.1 Mortality (No. of people of died within the year)
Tally
Total
1
2
3
4
5
42. 2 Mortality (Intervention)
Tally
Total
With
Without
Today, there have been 19 visitors (100 hits) on this page!
Dr. Meredith Grey: At the end of the day faith is a funny thing. It turns up when you don't really expect it. It's like one day you realize that the fairy tale may be slightly different than you dreamed. The castle, well, it may not be a castle. And it's not so important happy ever after, just that its happy right now. See once in a while, once in a blue moon, people will surprise you , and once in a while people may even take your breath away.
