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Head of the Family: Anastacia Guiterrez Family number: three (3)

Address: San Jose, Vigan City

Family Member Relation Sex Birth Date Marital Highest Occupation

No. Name to the Month Day Year Status Educational Type of Place
Head Completed Work
1 Anastacia Head F September 16 1941 Widow College Vendor Vigan
Gutierrez Graduate City
2 Evaristo Son M May 27 1963 Single Elementary Tricycle Vigan
Archie Graduate Driver City
Gutierrez
3 Freddie Son M January 9 1970 Single College N/A N/A
Gutierrez undergraduate

B. Home and Environment

Date assessed:
1.Y Home
a.Y Ownership: (¥) owned ( ) rented ( ) rent-free
b.Y Construction materials used: ( ) Light (¥) Mixed ( ) Strong
c.Y Number of rooms used for sleeping: 3
d.Y Lighting facilities: (¥) electricity ( ) kerosene ( ) others: specify
e.Y General sanitary condition: At the back yard, galvanized roof and other sharp
materials were not properly kept. There were also containers/cans filled with water
which can be a place for breeding of vectors carrying diseases.

2.Y Drinking Water Supply

Source: (¥) private ( ) public
Potability: They directly get the water from the pump. They don¶t boil, sterilize, and filter
the water. They just drink it as it is.
Distance from house: 1 meter
Storage: ( ) none (direct from faucet)
( ) large covered container with faucet
( ) large covered container without faucet
(¥) others, specify: pitcher/water jag

3.Y Kitchen
Cooking facility: ( ) electric stove ( ) gas stove (¥) firewood/charcoal
 Sanitary condition: In the kitchen, there were scattered kitchen utensils on the table and
also around the lavatory. On the cooking area, ashes and dusts were noticed around the
³kalan´.
Drainage facility: (¥) open drainage ( ) blind drainage ( ) none

4.Y Waste and disposal

a.Y Refuse and garbage
Container: ( ) covered (¥) open ( ) none
Method of disposal:
( ) hog feeding (¥) open burning
( ) open dumping ( ) garbage collection
( ) burial in pit ( ) others, specify:_____________
( ) composting
b.Y Toilet
Type:
( ) none ` ( ) pail system
( ) overhung latrine ( ) Antipolo
( ) open pit privy ( ) water-sealed latrine
( ) bored-hole latrine (¥) flush type
( ) others, specify:______________
Distance from house: 1meter
Sanitary condition: The toilet has no cover. There were mosquitoes flying around of
it and on the floor, pails and other materials for bathing were scattered like ³tabo´.
The flooring is also slimy and slippery which may cause accident to the family.

5.Y Domestic animals

KIND NUMBER WHERE KEPT
DOG 2 They were chained to the
posts outside the house
ROOSTER 15 They were tied outside the
house.
CHICKEN 10 They were kept in a
wooden basket outside the
house.
GOAT 6 They were tied in a field far
away from their house.

6.Y The Community in General

a.Y General sanitary condition: With what the community¶s sanitary status present,
different diseases may arise in the area or community. One is dengue fever for there
 were stagnant water seen in some part of community and also containers filled with
water. Typhoid fever may also develop. Though garbage bags and containers are
available, rubbishes and other waste products weren¶t still properly disposed and
segregated and some were scattered. Therefore, these will serve as breeding sites of
flies which may cause typhoid fever.
b.Y Housing congestion: (¥) yes ( ) no
c.Y Presence of breeding sites of vectors of diseases:
(¥) yes; specify: mosquitoes, flies
( ) none
d.Y Recreational facilities:
ËY Basketball court
ËY Playground
e.Y Availability of health care services(describe briefly):
ËY BP CHECK UP: every Sunday and Monday 8:00am-3:00pm
ËY IMMUNIZATION: the midwife is available every Wednesday and Friday
8:00am-3:00pm
f.Y Distance of house from nearest health care facility: 11 houses