CITY LOCAL HOUSING BOARD OF EL SALVADOR

INTAKE SHEET FORM

Date Interview:____________

I. SOCIO DEMOGRAPHIC PROFILE

Name:_______________________________________________
Age:______________
Sex:______________
Place of Birth:________________________________________________ Date of Birth:_____________________
Address:_____________________________________________________
Civil Status:_________________
Religion:___________________
Ethnic Affiliation:____________________________
Educational Attainment:_____________________________
No. of Children:_____________
Occupation:_________________________________ Income:_____________
No. of Children Working:___________ Type of House:__________________

II. FAMILY COMPOSITION

MEMBERS OF THE INCOME per
FAMILY MARITAL MONTH
AGE RELATION SEX OCCUPATION
STATUS
Monthly Daily

III. QUESTIONS
1. How long have you lived in El Salvador City?
[ ] 0-5 years [ ] 6-10 yrs [ ] 11-15 years
[ ] 16-20 years [ ] 21- 25 yrs [ ] 26-30 yrs [ ] 30 years and above
● Since when did you start living here?
[ ] 1950's [ ] 1960's [ ] 1970's [ ] 1980's
[ ] 2000-2004 [ ] 2005-2009 [ ] 2010-2014 [ ] 2015-2019
2. What is your means of living?____________________________________________________________________
● Other source of income:_________________________________________________________
● How much do you earn: In a day____________________ In a week:_____________________
3. Do you have land property?
[ ] YES [ ] NO
● If YES, how big is land property? ______________________________
● Location of the property? ____________________________________________________
4. Do you own or rent the house you residing now?
[ ] OWN [ ] RENT
5. Were you being informed about the Relocation? [ ] YES [ ] NO
6. What are your options where to reside?______________________________

IV. OTHER
1. Are you a 4P's beneficiary? [ ] YES [ ] NO
2. Senior Citizen pensioner? [ ] YES [ ] NO
3. PWD pensioner? [ ] YES [ ] NO
4. SSS Member? [ ] YES [ ] NO
5. GSIS Member? [ ] YES [ ] NO