Questionnaire Number: __________
A. RESPONDENT’S PROFILE
1. Sex 0 Male 1 Female
2. Age (as of last birthday) : ______ (Years)
3.. Marital Status : 1 Single 2 Married 3 Widowed 4 Separated
4. Is the respondent the household head? 1 Yes 2 No
5. Education of the respondent: 0 None
1 Elementary level
2 Elementary graduate
3 High school level
4 High school graduate
5 College level
6 College graduate, please specify degree:_______________________
7 Graduate school
. 6. Membership to an organization: Is any member of the household a member of any organization? Please fill in the table
below.
Name of Member Name of Organization Type (code)
Type of organization: 1 – Community/Civic 5 – Cooperative (credit, multipurpose, etc.)
2 – Water Association 6 – Religious organization
3 – Farmers Association 7 – Professional Organization
4 – Irrigator’s Association 8– Others (SPECIFY IN THE BOX ABOVE)
7. Main Source of Household Income: 1 Farming, Fishery, or Forestry
2 Government or Elected Government Official
3 Employed in a Private Firm or Individual
4 Entrepreneur, Self-Employed
5 None
6 Others, please specify ____________________
8. Household Size (all members): ______ # of Males Working: _______ # of Females Working: ________
9. Family Structure: 1 Nuclear 2 Extended (Relatives) 3 Extended (Non-Relatives)
10. Other Household Members: Excluding the respondent, indicate how many are:
1
Number of
Number of members
Number of Number of
Number of Members Who who are in
Members Who Members
Household are Currently the 4Ps
Have Scholarship Working to
Age Intervals Members Attending program
Programs Augment
School Household
Income
Less than 6 yrs old
6 – 12 yrs old
13 – 16 yrs old
17 – 21 yrs old
Older than 21 yrs old
B. HOUSING, UTILITIES, SANITATION (with reference to the household)
1. Do you own or rent your house and lot? 1 Own 2 Rented 3 Rent-Free
2. Roof Materials of housing unit (observe, do not ask): 1 – strong 2 – light 3 – mixed 4 - makeshift
3. Wall Materials of housing unit (observe, do not ask): 1 – strong 2 – light 3 – mixed 4 - makeshift
4. How long have you been living in the present housing unit? __________ Years
5. Do you have your own toilet? 1 Own (go to 5.1) 2 Shared/Common 3 None
CODE ROUTE
Own Proceed to B
1
6.1-B 6.2
Shared/
2 Proceed to B 8
Common
None 3 Proceed to B 8
5.1 If household owns a toilet: what type? 1 Water sealed 2 Sanitary pit 3 Others ________
5.2 Distance of toilet from household (write 0 if they own a toilet):__________ (Meters)
6. Do you have an electrical connection?
CODE ROUTE
Ye Proceed to B
1
s 6.1-B 6.2
2
No 2 Proceed to B8
6.1 Nature of connection: 1 Own Connection 2 Shared Connection
6.2 Electric Bill Last Month: ____________ Pesos
7. Do you have internet connection? 1 Yes 2 No
7.1 Internet Bill Last Month: ____________ Pesos
8. Where do you usually get your information? Pick 2 responses.
1 Radio
2 Newspaper
3 Social Media
4 Text Advisory
9. Where do you get most of the drinking water used by the household?
1 Level III (HH piped-in) 6 Open dug well
2 Level II (common faucet) 7 Rainwater (own collection)
3 Level I (developed spring) 8 Rainwater (common)
4 Private well 9 River/Creek/Spring
5 Public well 10 Others, please specify ________
9.1 Availability: 1 Always available 2 Sometimes not available 3 Frequently not available
9.2 How long will it take to fetch water from source): __________ Minutes
C. LIVELIHOOD AND INCOME
1. Monthly Household Income in PhP _____________
2. For each employed member, what is the primary occupation? Is the work full- or part-time? What is the monthly income or
daily wage? (Complete the table below.)
Relationship to Primary Income (Pesos)c
Tenure of Work b
Respondent Occupationa Daily Monthly
1 - FT 2 – PT
1 - FT 2 – PT
1 - FT 2 - PT
1 - FT 2 - PT
1 - FT 2 - PT
Column Codes:
a Primary Occupation
3
1 Professional, Technical and Related Workers
2 Administrative, Executive and Managerial Workers
3 Clerical and Related Workers
4 Sales Workers
5 Service Workers
6 Agricultural, Animal Husbandry and Forestry Workers, Fishermen, and Hunters (includes agricultural labor in other
farms)
7 Production and Related Workers, Transport, and Equipment Operators
8 Workers not classified by occupation
9 Members of the Armed Forces
b Tenure of Work: Encircle 1 if work is Full-Time, 2 if work is Part-Time
c Monthly/Daily Income: Ask for the monthly income in pesos. If respondent can easily recall daily or monthly wage, record
in appropriate column.
3. Is anyone not living in the household that contributes in the household income? 0 No 1 Yes
3.1 What is his/her relationship to the respondent? What is his/her primary occupation? How much does he/she contribute to
the household? Fill out the table below.
Primary Monthly
OccupationA Contribution to
Relationship to Respondent the Household
(Same Column Codes as 2
4. Have you undergone skills training? 0 No 1 Yes (Go to No.5)
CODE ROUTE
Ye
1 Proceed to C5
s
No 0 Proceed to D
5. Ask respondent s to list skill trainings he recalls he has undergone recently and complete the table below.
Awareness: If respondent mentions a project, consider him to be aware of it. (0 Not Aware1 Aware )
Necessity: Do you need this project? (0 Not Needed 1 Needed )
Access: Were you able to access this project? (0 Not Accessed 1 Accessed )
4
Satisfaction: Are you satisfied with the way the project was implemented? (0 Not Satisfied 1 Satisfied )
Effectiveness: Do you think the project is effective? (0 Not Effective 1 Effective )
Awaren Necessit Acces Satisfacti Effectivene
Government Intervention
ess y s on ss
0 1 0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1 0 1
0 1 0 1 0 1 0 1 0 1
D. ACCESS TO AND UTILIZATION OF HEALTH FACILITIES
CODE ROUTE
Ye
1 Proceed to D2
s
No 0 Proceed to D3
1. Have you undergone physical check-ups? 0 No 1 Yes
2. Frequency of physical check-up 1 Always 2 Frequent 3 Sometimes 4 Rarely
3. Do you suffer from serious illness? 0 No 1 Yes (Go to No.4)
CODE ROUTE
Ye
1 Proceed to D4
s
No 0 Proceed to D5
4. Please specify your illness ________________
5
5. What are the health facilities available in the area? Where can people in your community consult when they are ill? Fill out the
table below.
Accessed or
Consulted
Health Facilities Available? Satisfaction
when
needed?
Barangay Health Center 0-No 1-Yes 0-No 1-Yes 0-No 1-Yes
Rural Health Unit 0-No 1-Yes 0-No 1-Yes 0-No 1-Yes
Government Hospital/Clinic 0-No 1-Yes 0-No 1-Yes 0-No 1-Yes
Private Hospital/Clinic 0-No 1-Yes 0-No 1-Yes 0-No 1-Yes
Traditional Medicine Practitioner 0-No 1-Yes 0-No 1-Yes 0-No 1-Yes
Alternative Health Care 0-No 1-Yes 0-No 1-Yes 0-No 1-Yes
Pharmacy 0-No 1-Yes 0-No 1-Yes 0-No 1-Yes
Others:
Specify: 0-No 1-Yes 0-No 1-Yes 0-No 1-Yes
Specify: 0-No 1-Yes 0-No 1-Yes 0-No 1-Yes
E. PERCEPTIONS ON LIVING CONDITION
Some issues relevant to your community are listed below. We would like to ask your opinion, idea and some recommendations
concerning these issues. For each item below, please indicate your agreement/disagreement whenever applicable. Note that NOT
APPLICABLE option is included in case the issue is irrelevant to you. Please tell me what number best represents your
assessment as I read each statement. (USE SHOWCARD.)
READ THE STATEMENT ONLY, DO NOT READ THE ANSWERS, HAND DOWN THE SHOWCARD TO THE RESPONDENT WHILE
READING THE STATEMENTS. (The showcard will contain 5 varying faces indicating extent of agreement/disagreement to
the statement.)
0 – Not Applicable (1,2 levels of disagreement, 4,5 levels of agreement, 3 about to agree/disagree)
Strongly Agree Agree Neither Agree/ Nor Disagree Strongly Not
Disagree Disagree Applicable
SHOWCARD
Level of 5 4 3 2 1
Agreement
6
1. Housing unit is comfortable for the family. 5 4 3 2 1 0
2. Toilet is hygienic. 5 4 3 2 1 0
3. Cost of electricity is reasonable. 5 4 3 2 1 0
4. Water source is accessible. 5 4 3 2 1 0
5. Water is safe for drinking. 5 4 3 2 1 0
6. Water cost is reasonable. 5 4 3 2 1 0
7. School is accessible. 5 4 3 2 1 0
8. There is an improved quality of education. 5 4 3 2 1 0
9. Income is sufficient for household needs. 5 4 3 2 1 0
10. There are enough jobs available. 5 4 3 2 1 0
11. There is enough training on possible livelihood. 5 4 3 2 1 0
12 There is enough food for the family. 5 4 3 2 1 0
13. It is easy to take public transportation. 5 4 3 2 1 0
[Link] is an access to public information. 5 4 3 2 1 0
15. There is a general feeling of satisfaction in the
5 4 3 2 1 0
province
16. I am contented with the way our needs are provided
5 4 3 2 1 0
by the provincial government.
17. Our living conditions now are much better than it was
5 4 3 2 1 0
three (3) years ago.