BARANGAY MANAGEMENT INFORMATION SYSTEM 9. Do you use iodized salt (Gumagamit 17.

Structure of the 1 Duplex 5 Multi-Unit Residence

FAMILY DATA SHEET ng iodized salt)? ☐ Yes (Oo) ☐ No (Hindi) house: 2 Commercial/Industr 6 Single House
10. Do you practice Family Planning
CERTIFICATION
I hereby certify that the data gathered in this questionnaire was (Gumagamit ng family planning)? ☐ Yes (Oo) ☐ No (Hindi) “Kaanyuhan ng bahay”
3
ial/ Agricultural
Extension
7 Other Housing Unit

obtained/checked by me personally according to the instructions given. ☐ Not applicable (Hindi 4 Institutional Living
Quarters
naaayon)
11. If yes, what method/s of family planning (Kung oo, ano paraan ng 18. External housing 1 Asbestos/Glass/Others
Name and Signature of Enumerator Date Signed
family planning ang ginagamit)? walls: 2 Bamboo, Sawali, Cogon, Nipa
Natural Artificial “Uri ng yari ng dingding 3 Concrete/Brick/Stone
Name and Signature of Respondent Date Signed 1 Basal Body Temperature 8 Condom ng bahay” 4 Galvanized Iron, Aluminum
2 Cervical Mucus 9 Depo Injection 5 Half-Concrete, Brick, Stone, Half Wood
FAMILY IDENTIFICATION 3 Lactational Amenorrhea Method 10 IUD 6 Makeshift, Salvaged, improvised
Pangalan ng Puno ng Pamilya 4 Rhythm 11 Ligation 7 Wood
First name: Middle name: 5 Standard Days Method 12 Pills 8 No walls/not reported
Last name: Qualifier: 6 Sympto-thermal Method 13 Vasectomy 19. Roof construction 1 Bamboo, Sawali, Cogon, Nipa
7 Withdrawal 14 Others 2
Address material: Galvanized/iron
ENVIRONMENT AND SANITATION
House No.: Street/Subd: “Materyales ng bubong 3 Makeshift, Salvaged, improvised materials (ex.
12. Toilet facilities: Type 1 Owned solely 2 Shared
by family ng bahay” plastic/sack/tarpaulin)
Purok: Barangay: “Uri ng
palikuran” 1 Water sealed with 4 Mixed materials but more of
Municipality: Province: sewage/septic tank
❑ ❑ cogon/nipa/anahaw
Household Condition Family Status
2 Covered Pit ❑ ❑ 5 Mixed materials but more of Galvanized/iron
3 Open Pit ❑ ❑ 20. Floor material - first 1 Bamboo 5 Wood
❑ Resident ❑ Owner (main family) ❑ Active 4 Thrown Anywhere ❑
❑ Non-resident ❑ Extended ❑ Inactive floor: 2 Cement 6 Soil
5 Others (Pail
System, Etc.)
❑ “Materyales ng sahig ng 3 Cemented with 7 Soil with linoleum
FAMILY INFORMATION 1 Owned solely bahay- unang linoleum
13. Source of water: 2 Public 3 Shared
1. No. of family members (Bilang ng Miyembro ng pamilya)? by family palapag” 4 Cemented with tiles
“Pinagkukunan ng
2. Year first resided in the brgy (Unang taon nanirahan ang tubig” 1 Dug well ❑ ❑ ❑
2 Community water 21. Lighting used: 1 Battery
puno ng pamilya sa Brgy)?: Electricity
system
❑ ❑ ❑ “Pailaw na ginagamit sa 2 Candle
*Check all that
3. Household heads place of origin before applies. 3 Tubed piped, deep bahay” 3 Solar power 6.1 With electric meter
well
❑ ❑ ❑
living in the brgy (Lugar na Pinanggalingan 4 Kerosene 6.2 Without electric
ng Puno ng Pamilya)? (Municipal, Province) 4 Tubed piped, Others, specify:
shallow well
❑ ❑ ❑ meter
_________________
4. Contact number of the head of the family: 5 Spring, lake, river,
rain
❑ 22. Cooking facilities: 1 Charcoal
Telephone service provider Contact number (Landline/Mobile) 4 LPG
6 Peddler ❑ “Ginagamit sa pagluluto” 2 Electricity
5 Wood
7 Buy mineral water ❑ 3 Kerosene
8 Others: 23. Garbage disposal: 1 Burned 5 River
14. Source of electricity: 1 Barangay generator Power producer/ “Paraan ng pagtatapon 2 Collected 6 Thrown anywhere
“Pinagkukunan ng 2 Battery cooperative, specify: ng basura” 3 Composting 7 Waste
5. Type and number of vehicle owned (Uri at bilang ng pag-aaring
kuryente/enerhiya” 3 Biogas 4 Open Pit Segregation
sasakyan)? ____________________
4 Own generator 24. Location of house: Along the:
Vehicle (Sasakyan) Number Vehicle Number 6 None
*Check all that applies. 5 Solar 1 Irrigation canal
(Bilang) (Sasakyan) (Bilang) “Lugar na kinatatayuan National/Provincial road
1 Bicycle 9 Pedicab 15. House 1 Owned ng bahay” 2 Lakeshore 11 Along (0-10m)
acquisition: 2 Rented 3 Railroad 12 Near(11-500 m)
2 Boat 10 Pick-Up “Pagmamay-ari ng 3 Being Amortized (hinuhulugan)
4 Riverbank 13 Far (>500 m)
3 Bus 11 Pump Boat bahay” 4 Being occupied for free with consent (nakatira ng
libre na may pahintulot) 5 Seashore
4 Car 12 Raft
5 Being Occupied for free without consent (nakatira Foot of: Municipal road
5 Jeepney 13 SUV 6 Hill
ng libre na walang pahintulot 14 Along (0-10m)
6 Motorboat 14 Tricycle 6 Caretaker (taga-bantay ng bahay) 7 Mountain 15 Near(11-500 m)
7 Motorcycle 15 Truck 7 Family owned (pagmamay-ari ng pamilya) 16 Far (>500 m)
8 Owner Type Jeep 16 Van 8 Government owned (pagmamay-ari ng gobyerno) 8 On a hill Barangay road
16. Lot ownership: 1 Owned 17 Along (0-10m)
9 On the mountain
HEALTH INFORMATION “Pagmamay-ari sa 2 Rented 18 Near(11-500 m)
lupa” 3 Being Amortized (hinuhulugan) 10 Rice field 19 Far (>500 m)
6. Do you plant herbal plants (May 4 Being occupied for free with consent (nakatira ng
tanim na halamang gamot)? ☐ Yes (Oo) ☐ No (Hindi) libre na may pahintulot)
20 Others (waiting shed, under the bridge, cart,
etc.)
5 Being Occupied for free without consent (nakatira
7. If yes, what herbal plants (Kung ng libre na walang pahintulot 25. Location of house
Oo, anong uri ng halamang gamot)? 6 Caretaker (taga-bantay ng bahay) according to 1 Coastal 2 Lowland 3 Upland
8. Do you have a vegetable garden 7 Family owned (pagmamay-ari ng pamilya) “ecological setting”:
(May tanim na gulay)? ☐ Yes (Oo) ☐ No (Hindi) 8 Government owned (pagmamay-ari ng gobyerno)
 AGRICULTURAL INFORMATION:

26. Kabuuang laki ng lupang sinasaka at lugar: 32. Uri ng Palaisdaan 1 Freshwater 2 Freshwater 3 Brackish water 4 Marine fish 5 Backyard
Kalagayan sa Pag-aari ng Lupang (Type of Aquaculture Farm) cage/pen fishpond fishpond cage/pen
Kapag tenant, sino ang
Lawak (ektarya) Lugar ng lupang sinasaka Sinasaka (Status of Ownership in the Farm
may-ari ng lupa
(If Farming): Owned, Leased, Tenanted
33. Uri ng Kagamitan/makinarya sa pagsasaka 35. Hayop na Pangkain na inaalagaan (Farm Animals Raised)
(Agricultural Machineries/Equipment/ToolsOwned): Animals # of Animals # of Animals # of
Machineries Bilang Machineries Bilang Heads Heads Heads
Rice mill 4-wheel tractor Baboy (barako) Kabayo Pugo
Feedmill Sprayer (Knapsack) Baboy (inahin) Kalabaw Itik
Agricultural/Fishery Products: Grain Drying Facility Sprayer (Power) Baboy (biik) Kambing Manok (layer)
28. Uri ng Lupang Sinasaka 29. Lawak ng lupa bawat pananim Warehouse Araro Baboy (grower) Bengala Manok
(Type of Farm) 30. Lugar Thresher Suyod (broiler)
27. Pananim/ Produkto (Product) Kabuuang laki Bilang ng Puno ng
Irrigated, Rainfed, Upland, (Brgy/Mun/Prov)
(ektarya) pananim Reaper Waterpump Baka Tupa Manok (native)
Lowland Others, specify
Corn Sheller Hand tractor Bibi Pabo Manok
(sasabungin)
34. Uri ng Kagamitan/makinarya sa pangingisda 36. Pet Animals
(Fishing Machineries/ Equipment/ Tools Owned: #of #of # of
Machinery Bilang Machinery Bilang Animals Animals Animals
Heads Heads Heads
Sima o pangawit (barb) Motorized Fishing Boat Dog/Puppy Rabbit Fish
31. Kalagayan sa pag-aari ng
4 Fishpond Leasehold Cat/Kitten Monkey
palaisdaan (Status of Aquaculture 1 Owned 2 Leased 3 Tenanted Lambat 3 tons pababa (mun fishing vessel)
Agreement (FLA)
Farm Ownership) Bird Snake
Non-motorized Fishing Boat 3 tons pataas (commercial)
FAMILY MEMBERS INFORMATION:
Status (If Registered Buntis
Relation Main Other Type of
Name dead, write Birthday Place of Registered COMELEC Place of Civil Organi- Name of Educational Status of Degree/ Status Country/ Monthly (Yes
to HH Sex Religion Skills Ethnicity Studying Source of Sources of Sakit Kapansanan Health
(First/ Middle/ Last) cause of (mm/dd/yr) Birth Birth at Civil Voter in the Registration Status zations School Level Schooling Course of Work OFW Place of Income or
Head (4) (11) (12) (14) (15) Income Income (26) (27) Insurance
(1) death) (5) (6) Registrar barangay (9) (10) (13) (16) (17) (18) (19) (21) (22) Work (25) No)
(2) (20) (24) (28)
(3) (7) (8) (23) (29)
1.
HH
2.

3.
4.
5.

6.

7.

8.

9.

10.

(2) Relation (8) (10) (14) (17)

10. Live in (3) (4) (5) (6) (7) (9) M-Married; Mga Hal.: (15) Write (18) (19) (20) (21) (22) If OFW, (25) (28)
1. Adopted 11. Niece/Nephew Yes–if
A–Active M-Male Write Write Yes- registered Write NM- Not abilidad Bicol Yes- NS - No G- Write Write actual P- Write Y write Add see below
2. Brother/Sister 12. Others T- F- complete Municipal Registered in the brgy Barangay, Married/Co Studying Schooling Graduate course if work if OFW country income selections
Brother-in-law 13. Parent/s mmon law Ibanag Perman
Transferred Female year and Birth
3. Child (Anak) 14. Parent-in-Law No–if not Municipality spouse halimbawa Ilocano NYS- Not Yet UG-Under- college
ent
where of main
D-Died i.e. Province and welding, Ivatan No - Not Studying graduate graduate working and
4. Daughter/Son 15. Relative registered S-Single
1/25/2015 No-Birth in the brgy Province SP-Solo singing, Studying DC-Day Care S- NP- Not other
in-law 16. Sister-in-law Moro
5. Employee 17. Spouse not Parent W- carpentry, Pangasine or not yet K-Kinder Studying Perman sources
NR-if not
6. Grandchild 18. Step registered registered Widow dancing nse studying Gr 1, 2…12 ent of
(Apo) Son/Daughter in any brgy LS-Legally Sambal Elementary income
7. Grandparent/s 19. Step-Parent Separated
Tagalog 1st, 2nd…year
8. Head of the 20. Student NA- if not A-Annulled
yet voter Visayan at college or HS
Family Sep-
9. Housemaid (age 0–17 Separated iba pa.
yrs old)
(28) Health insurance: 1 No health insurance; 2 Active member of PhilHealth w GSIS (Philippine government) ; 3 Active member of PhilHealth w SSS (private companies); 4 Active member of OWWA; 5 Active member self-paying Philhealth; 6 Present member of PhilHealth non-paying member;
7 Active member of Health maintenance; 8 Active member community/ cooperative health scheme Organization; 9 Active member private health insurance; 10 Dependent health insurance; 11 Local Health insurance Halimbawa: health insurance na ginagamit lang sa mga ospital ng probinsya o
munisipyo; 12 Present member of Philhealth LGU halimbawa: 4Ps beneficiary, PNOY; 13 Philhealth member dependent
HEALTH INFORMATION FOR CHILDREN AGED 0-71 MONTHS:
Date last 2 Vit. A 3 Vit. A 4 Vit. A 1 Presently 2 Presently BF
Name 1 BCG 2 Pentavalent1 3 Pentavalent2 3 Pentavalent3 4 OPV1 5 OPV2 6 OPV3 7 HVB1 8 HVB2 9 HVB 3 10 AMV 11 MMR 1 Iron Exclusively BF
dewormed (April) (Oct.) (when sick)