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Name of Student:___________________________________

Family names of the household: H1_________________ H2________________


H3_________________ H4________________

SOCIAL INDICES
I. Education: Please indicate the number of individuals (only for individuals who are 5-25
years old)
H1 H2 H3 H4
In School
Out of School
Not Enrolled
Graduate
Dropped

A. For enrolled individuals only: Please indicate the number of individuals


Age Range
5-9 y/o 10-14 y/o 15-19 y/o 20-24 y/o 25
Male Female Male Female Male Female Male Female Male Female
H1
H2
H3
H4

B. Educational Level of Individuals who are 5-25 y/o. Please indicate the number of
individuals
Preschool Elementary Secondary College Vocational
H1
H2
H3
H4

C. Educational Attainment of individuals who are > 25 years old. Please indicate the number of
individuals
Elementary Elementary High High College Vocational
level Graduate School School level
Level Graduate
H1
H2
H3
H4
II. Transportation: Please indicate the number of individuals who utilize either of the
following means of transportation.
Means of Transportation
Jeep Sikad Taxi/PU Car Motorcycle Bicycle Bangka/Boat Bus
H1
H2
H3
H4

III. Communication and Trimedia:


H1 H2 H3 H4
Number of Television
Number of Radio
Number of Telephone
Number of mobile/cellular phone
Cable connection(w/ or w/o)
Internet connection (w/ or w/o)
utilizes mail (yes/no)
Utilizes news papers/magazines
(yes/ no)

IV. Recreation. Just put a check for a household who utilizes either of the following modes of
Recreation.
Modes of Recreation H1 H2 H3 H4
Watching TV
Watching DVD
Videoke
Sports
Disco
Reading books, newspapers, magazines
Listening to radio
Computer games

V. Vices: Please indicate the number of individuals who utilize either of the following types
of vices.
Types of Vices H1 H2 H3 H4
Drinking alcohol
Cigarette Smoking
Gambling
Drugs
Computer Games/ Arcade
VI. Housing Condition
A. Type of Housing Material. Just put a check on either of the following types of housing
material your household have.
Simple Concrete Mixed
H1
H2
H3
H4

B. Crowding Index. Just put a check on either of the following crowding index for each
household. Note: Crowding index = number of persons/1 sq. m
1 person/1 sq. m or ≥ 2 persons/ 1sq.m 3 persons/ 1sq.m
1 sq. m.
H1
H2
H3
H4
C. House Ownership Status. Just put a check on either of the following type of ownership for
each household.
Owned Rented Free
H1
H2
H3
H4

D. Lot Ownership. Just put a check on either of the following type of ownership for each
household.
Owned Rented Free
H1
H2
H3
H4

E. Electricity and Water Supply. Just put a check on either of the following (w/ or w/o; Legal
or Illegal)
Availability of Electricity Legality of Electrical Water Supply
connection
with without Legal Illegal with without
H1
H2
H3
H4
F. Housing Ventilation. Just put a check on either of the following: well ventilated or not well
ventilated. Note: Well ventilated has at least three windows (L= ≥ 1sq.m x W= ≥ 0.5sq.m)
Well ventilated Not well ventilated
H1
H2
H3
H4

G. Sources of Public Assistance. Just put a check on either of the following sources of Public
assistance utilize by each household.

Brgy. Brgy. Purok Police Canaway DSWD NGO Others


Health Officials Officers Station Satellite
Center
H1
H2
H3
H4

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