COMMUNITY PROFILING: HOUSEHOLD INTERVIEW GUIDE

A. IDENTIFICATION
I. Name of the Community: II. Household III. Coordinates: IV. Name of Respondent: V. Date
No: A.1 Latitude: Interviewed:
A.2 Longitude:
B. HOUSING CHARACTERISTICS
1. In what type of building 2. What type of construction materials 3. What type of construction materials [Link] type of construction
does the household reside? are the roofs made of? are? materials are the floors made of?
_______________________ _______________________________ _________________________________ ___________________________________
C. HOUSING AND HOUSEHOLD CHARACTERISTICS
5. How many household members are overseas workers? ____________________________________________
6. How many nuclear families are there in the household? ____________________________________________
7. Is any member of the household pregnant? ______________________________________________________
8. Is any member of the household a solo parent? ___________________________________________________
9. Is any member of the household disabled? _______________________________________________________
D. DEMOGRAPHIC INFORMATION AND SOCIO – ECONOMIC PROFILE
10 11 12 13 14 15 16 17 18 19 20 21 22
N Household
U
Members Date of Ethnicity Why is ___
Educational Nature of
M Birth Religious Marital by not Occu Salary/ Registered
B SURNAME Relationship Gender Attainment Employme
E FIRST NAME
MM/ DD/ Affiliation status blood? attending pation
nt Wages voter
R YYYY school?
MIDDLE NAME

10

23. ARE THERE MORE THAN 10 MEMBERS IN THIS HOUSEHOLD? ________1 YES, USE NEW FORM _______________2 NO
E. HEALTH AND NUTRITION
24. During the past 12 months, did you or any member of
25. During the last illness of any member of the household, (24) where did you go to avail medical treatment?
the household avail of medical treatment for any illness?
 Public hospital (National) Rural health units Public hospital (District)
 Yes No Did not get sick  Public hospital (Municipal/City) Barangay Health Station Public hospital (Provincial
 Private hospital/clinic Non-medical/non-trained Hilot/Personnel Others, specify
F. HEALTH AND OTHER CHARACTERISTICS OF HOUSEHOLD MEMBERS G. CRIME H. NUTRITION
26 27 28 29 30 31 32 33 34
N FOR 60 FOR 5 YEARS
IF YES IN IF YES IN
IF YES IN (8) YEARS OLD IF YES IN (30) OLD AND
U (6) (7)
AND ABOVE Has __ BELOW
M Write the first names What been a victim
Is ____a a) What crime/s
B of each member Does of crime in the NUTRITIONAL
solo parent type Does __ was/were __a
E Is____ ___have past 12 STATUS OF Common
taking care of disability have a Senior victim of?
R pregnant? a PWD’s months? CHILDREN 0-5 Illness
of a child/ does Citizen’s ID? b) Where did the
FIRST NAME ID? YEARS OLD
children? ____have? crime happen?
1

10

Form No. TSU-ESO-SF - 47 Revision No. 00 Effectivity Date: July 17, 2019 Page 1 of 2
I. WATER AND SANITATION
35. What is your household's main source of water supply? 36. What type of toilet facility does the household use?
 Faucet Spring  Water-sealed, sewer septic tank Closed pit/ Open pit
 Piped deep well Lake, river, rain, and others  Water-sealed, other depository None (bodies of water, backyard,
 Dug well (e.g. balon) Bottled water (purified, distilled, mineral) public spaces)
J. HOUSING
37. What is the tenure status of the housing unit and lot occupied by your 38. What is the household's main source of cooking fuel?
household?
 Own or owner-like possession of house and lot  Electricity Kerosene Animal dung
 Rent house/room including lot  LPG Agricultural crops Straws/Shrubs/Grass
 Own house rent lot  Charcoal/Coal residues (e.g. coconut midribs, Others, specify
 Living in a public space  Wood coconut shells, coconut/corn husks, rice hulls, etc.)
39. Is there any electricity in your community? 40. What is the source of electricity?
 Yes  Electric company Battery Others specify
 No  Generator Solar
K. WASTE MANAGEMENT
41. What is the system of garbage disposal adopted by the household? 42. Who collects the garbage? 43. How often is the garbage collected?
 Garbage collection  Municipal/city collector  Daily
 Burning  Barangay collectors  Once a week
 Composting  Private collectors  Twice a week
 Others, specify  Thrice a week
 Recycling
 Others, specify
 Waste segregation
 Pit with cover
 Pit without cover
 Throwing of garbage in river, vacant lot
 Others, specify____________________________
L. CLIMATE CHANGE AND DISASTER RISK MANAGEMENT
44 N. SOURCE OF INCOME
During the past 12 months, which of the following calamities affected your household: 45. ENTREPRENEURIAL ACTIVITIES
 Typhoon  CROP FARMING AND GARDENING
 Flood  LIVESTOCK AND POULTRY RAISING
 Drought  FISHING
 Earthquake  FORESTRY AND HUNTING
 Volcanic eruption  WHOLESALE AND RETAIL
 Landslide/mudslide  MANUFACTURING
 Tsunami  COMMUNITY, SOCIAL, RECREATIONAL, AND PERSONAL SERVICES
 Fire  TRANSPORTATION, STORAGE AND COMMUNICATION SERVICES
 Forest fire  MINING AND QUARRYING
 Armed conflict  CONSTRUCTION
 Others, specify  ACTIVITIES NOT ELSEWHERE CLASSIFIED

M. HUNGER O. AGRICULTURE-FARMING
46. In the last 3 months, did it happen even once that your household experienced 48 What is the tenure status of the agricultural land being tilled by the household?
hunger and did not have anything to eat? ____________________________________________________________________
 Yes No
49. What is the area of the agricultural land? ______________________
47
50. What are the temporary and permanent crops did your household harvest?
During the past 12 months, did you or any member of your 1. _____________________________________________________________________
household receive or avail of any of the following programs? Remarks 2. _____________________________________________________________________
3. _____________________________________________________________________
TYPE OF PROGRAM 4. _____________________________________________________________________
 Sustainable Livelihood Program (DSWD) 5. ______________________________________________________________________
 Food for School
 Food for Work 51. What are the agricultural equipment/ facilities does the household use?
 Cash for Work • ______________________________________
 Social Pension for the Indigent Senior Citizens • ______________________________________
 Pantawid Pamilyang Pilipino Program (4Ps) • ______________________________________
 Agrarian Reform Community Development Program (ARCDP)
 Training for Work Scholarship Program (TWSP) P. OTHERS
 Community-Based Employment Program (CBEP) 52. What are the appliances/ vehicle owned by the household?
 Philhealth 1. __________________________ 2. __________________________
 Other health insurance (Maxicare, Medicare, Intellicare, etc.) 3. __________________________ 4. __________________________
 Health assistance 5. __________________________ 6. __________________________
 Supplemental feeding 53. What other organization’s assist your community? What type of Assistance?
 Education/scholarship program Organizations Assistance
 Credit program
 Housing program
 Other programs, specify

TARLAC STATE UNIVERSITY

Kami po ang kawani ng Tarlac State University – Extension Services office (TSU – ESO) na humihingi ng pahintulot na makalikom ng mga
datos na nakasaad sa mga palatanungan na ito. Ito po ay gagamitin sa pananaliksik sa pagtutukoy at paggawa ng mga nararapat na plano sa ilalim ng
Extesion Services partikular sa Community Development.

Ang mga datos na nakalap ay tanging gagamitin sa pananaliksik at aming pong tinitiyak na ang inyong mga sagot at tugon ay mananatiling
confidential.

Maraming salamat po!

Form No. TSU-ESO-SF - 47 Revision No. 00 Effectivity Date: July 17, 2019 Page 1 of 2