Beruflich Dokumente
Kultur Dokumente
I. Demographic Variables
Name
Religion
Age
Sex
Civil Status
Educational Attainment
1
2
3
4
5
6
7
8
9
10
Based on Decent:
[ ] Patrilineal
[ ] Matrilineal
[ ] Bilateral
Based on Authority
[ ] Patriarchal
[ ] Egalitarian
[ ] Matriarchal
[ ] Matricentric
1. Means of Communication
[ ] Landline
[ ] Mobile Phone
[ ] E-mail
[ ] Postal Mail
[ ] Others: _________________
2. Modes of Transportation
[ ] Tricycle
[ ] Jeepney
[ ] Pedicab
[ ] Bus
[ ] Other: _______________
B. Economic Indicators
Name
Employment
Status
Occupation
Place of Work
Income
Salary
Wage
1
2
3
4
5
1. Total Monthly Income
[ ] No Income [ ] 1,000-2,999
[ ] 1-999
[ ] 3,000-4,999
C. Environmental Indicators
1. Type of Neighborhood
[ ] Congested
[ ] Squatter
[ ] 5,000-6,999
[ ] 7,000 and above
2. Lot Ownership
[ ] Owned
[ ] Rented
[ ] Squatting
3. House Ownership
[ ] Owned
[ ] Rented
[ ] Free
4. Type of House
[ ] Concrete
[ ] Mixed w/ Cement
[ ] Makeshift
[ ] Mixed w/ Wood
[ ] Other: ______________
5. Ventilation
[ ] With
How: __________
[ ] Without
6. Lighting Facilities
[ ] W/ Electricity
[ ] W/O Electricity
How: ____________
7. Cooking Environment
[ ] Backyard
[ ] Sidewalk
[ ] Other:______________
8. Cooking Facility
[ ] LPG
[ ] Charchoal
[ ] Kalan de Bomba [ ] Wood
[ ] Other: ____________
9. Water Source
[ ] MWSS
[ ] Deep Well
[ ] Artesian
Ownership
[ ] Owned
[ ] Shared Distance: _____
D. Cultural Factors
1. Race:
__________________________
2. Ethnicity:
4. Birth Attendant
[ ] Hilot
[ ] Midwife
[ ] MD
[ ] No Child
5. Herbal Medicine
[ ] Taheebo
[ ] Sambong
[ ] Lagundi
[ ] Oregano
6. Family Planning
[ ] Pills
[ ] Condom
[ ] Surgery [ ] Withdrawal
__________________________
3. Language:
__________________________
[ ] Other: _____________
[ ] Bayabas
[ ] Other: __________
[ ] None
[ ] Other: __________
Age
BCG
DPT
OPV
Measles
Weight
Height
Age
Date
Disease Suffered
Medical Attendance
With
Without
Treatment
Age
Date
Disease Suffered
Medical Attendance
With
Without
Treatment
Age
Date
Disease Suffered
Medical Attendance
With
Without
Treatment
1
2
3
4
5
3. Past Illness (past 6 months)
Name
1
2
3
4
5
4. Death within 5 years
Name
1
2
3
4
5
IV. Health Resource
A. Manpower Resources
1. Health Resources
[ ] Health Center
[ ] Private Clinic
No: ___
[ ] Hospital
No: ___
[ ] Other: _______ No: ___
[ ] Midwife
[ ] BHW
No: _____
No: _____
[ ] Midwife
No: _____
Capacity: __________
[ ] Midwife
No: _____
Capacity: __________
V. Political/Leadership Patters
1. Barangay Officials
Barangay Captain: _________________________
Kagawad: ________________________________
Tanod: __________________________________
SK: _____________________________________
Others: __________: _____________________________
__________: _____________________________
__________: _____________________________
2.Relationship with the Barangay Officials
[ ] Good
[ ] Fair
[ ] Poor
Good: No Conflicts
Fair: Some Conflicts
Poor: Many Conflicts
3. Cause of social conflict/unification: __________________________________________________________
4. Practices/ Approach to settle conflict or promote bonding: ________________________________________
Interviewee: ____________________________________
Interviewer: ____________________________________
Date: _________________
Section/Group: _________