1. Community-Based Monitoring System
Household Profile Questionnaire
CONFIDENTIALITY
A. IDENTIFICATION
I. Identification of Location
a. Province : Cebu______________________________________
b. City/Municipality :_Consolacion__________________________________________
c. Barangay : _Sac-sac_________________________________________
d. Purok: _Asucena_________________________________________
B. Demography Frequency Percentage
4. Sex
1. Male 3 60%
2. Female 2 40%
5. Date of birth
6. AGE
0-5 0 0%
6 – 10 0 0%
11 – 15 0 0%
16 – 20 0 0%
21 – 25 1 20%
26 – 30 1 20&
31 – 35 1 20%
36 – 40 0 0%
41 – 45 0 0%
46 – 50 0 0%
51 – 55 0 0%
56 – 60 0 0%
61 – 65 2 40%
7. Marital status 1 - Single 3 60%
2 - Legally Married 2 40&
3 - Widowed 0 0%
4 - Divorced/ Separated 0 0%
5 - "Live in" 0 0%
6 - Unknown 0 0%
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2. 8. Religious affiliation
1 - Catholic 5 100%
2 - Protestant 0 0%
3 - IglesianiKristo 0 0%
4 - Aglipay 0 0%
5 - Islam 0 0%
6 - Others, specify 0 0%
7 - None 0 0%
1 - Catholic
C. EDUCATION AND LITERACY
9. Attending school
Yes 1 20%
No
10. What grade or year
1. No Grade Completed
2. Day Care
3. Kindergarten
4. Grade I
5. Grade II
6. Grade III
7. Grade IV
8. Grade V
9. Grade VI
10. Elementary Graduate
11. 1st Year HS
12. 2nd Year HS
13. 3rd Year HS
14. 4th Year HS
15. HS Graduate
16. 1st Year COLLEGE 1 20%
17. 2nd Year
18. 3rd Year
19. 4th Year
20. College Graduate
21. Post Grad w/ units
22. Graduate (specify PhD
/Master's course)
11. Type of school?
1. Public 0 0%
2. Private 5 100%
3. Vocational
12. Highest educational attainment?
1. No Grade Completed 1
2. Day Care
3. Kindergarten
4. Grade I
5. Grade II 1 20%
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3. 6. Grade III
7. Grade IV
8. Grade V
9. Grade VI
10. Elementary Graduate 1 20%
11. 1st Year HS
12. 2nd Year HS
13. 3rd Year HS
14. 4th Year HS
15. HS Graduate 2 40%
16. 1st Year COLLEGE
17. 2nd Year
18. 3rd Year
19. 4th Year
20. College Graduate
21. Post Grad w/ units
22. Graduate (specify PhD
/Master's course)
13. Can __ read and write a simple
message in any language or dialect
Yes 5 100%
No 0 0%
D. COMMUNITY & POLITICAL PARTICIPATION
14. Member of a community
organization
Yes 2 40%
No 3 60%
15. Name of community organization
1 - Religious
2 - Youth
3 - Cultural
4 - Political
5 - Women’s
6 – Agricultural
7 - Labor
8 – Civic
9 – Cooperatives
10 - Senior citizens 2 40%
11 - Others, specify
16. Registered voter in the municipality
Yes 5 100%
No 0 0%
17. Voted in the last election
Yes 4 80%
No 1 20%
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4. E. NUTRITION
18. NUTRITIONAL STATUS OF CHILDREN
0-5 YEARS OLD
1) Above normal 2) 3)
4) Normal
5) Below normal
F. ECONOMIC ACTIVITY
19. Have a job or business during the
last three months
Yes 1 20%
No 4 80%
20. Primary job, occupation or business
during the past three months
1. Officials of government and 1 20%1
special interest
organization, corporate
executives, managers,
managing proprietors and
supervisors
2. Professionals
3. Technicians and associate
professionals
4. Clerks
5. Service workers and shop
and market sales workers
6. Farmers, forestry workers
and fisherfolk
7. Trades and related workers
8. Plant and machine
operators and assemblers
9. Laborers and unskilled
workers
10. Special occupations
21. Nature of employment
1. Permanent job, business
unpaid family work
2. Short-term or seasonal or
casual job/ business
3. Worked on different jobs
on day to day or week to
week
22. Average Monthly Income
1. No Income
2. Below P5,000
3. 5,001 – 10,000 1 20%
4. 10,001 – 20,000
5. 20,001 – 40,000
6. 40,001 – 60,000
7. 60, 001 – 100,000
8. 100,001 - above
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5. 23. Classification of job or employment
1.Worked for a household
2.Worked for a private 1 20%
establishment
3.Worked for
government/government
corporation
4.Self employed without
employees
5.Employer in own family
operated farm or business
6.Worked with pay on own
family operated farm or
business
7. Worked without pay on
own family operated farm
or business
24. Looking for work/try to establish
business during the past three
months
Yes 4 80%
No
25. Activities to look for work
1. Registered in public
employment agency
2. Registered in private 1 20%
employment agency
3. Approached employer 2 40%
directly
4. Approached relatives /
friends
5. Placed or answered private
advertisements
6. Others (specify)
26. Reasons did not look for work during
the past three months
1. Believes no work is available
2. Awaiting results of previous
job application
3. Temporary illness/ disability
4. Bad weather
5. Waiting for rehire/job recall
6. Too young/old, retired
permanently disabled
7. Housekeeping
8. Schooling
9. Other reasons (specify)
27. The last time looked for work
28. Opportunity for work existed during
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6. the last 3 months or the next month,
would __ have been available
29. Willingness to take up work during
the past 3 months or within the next
month
G. HEALTH
31. has been sick and unable to engage
in normal activities
Yes 0 0%
No 5 100%
32. nature of illness
1. Diarrhea
2. Pneumonia
3. Stomach ailment
4. TB/Pulmonary illness
5. Dengue fever
6. Typhoid
7. Asthma
8. UTI
9. Animal Bites
10. Skin Disease
11. Cough/Cold
12. Flu/Fever
13. Others pls specify:
33. avail of medical treatment for the
illness
Yes
No
34. Where did you go to avail medical
treatment
1. Public hospital (Provincial
hospital)
2. Public hospital
(Municipal/City hospital)
3. Public hospital (District
hospital)
4. Public hospital (National)
5. Private Hospital/Clinic
6. Rural Health Units 1
7. Brgy. Health Center
8. Non-medical/non-trained
Hilot/Personnel
9. Others, specify
35. reason why did not seek health care
1. Illness was not severe
2. Lack of available health
care
3. Cost of medicine
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7. 4. Distance
5. Lack of transportation
6. No one available to take
the child
7. Other, pls specify
8. Illness was not severe
H. PEACE AND ORDER
36. member of the household been a
victim of any crime
Yes 0 0%
No 5 100%
37. type of crime
1. Murder/ Homicide
2. Theft/ Robbery
3. Rape
4. Physical Injury
5. Others, specify
I. WATER AND SANITATION
38. main source of drinking water
1. Community water system 1 20%
- own use
2. Community water system
- shared with other
households
3. Artesian deep well - own
use
4. Artesian deep well -
shared with other
5. Artesian shallow well -
own use
6. Artesian shallow well -
shared with other
households
7. Dug/shallow well - own
use
8. Dug/shallow well - shared
with other households
9. River, stream, lake, spring
and other bodies of water
10. Bottled
water/Purified/Distilled
water
11. Tanker truck/Peddler
12. Other sources (specify)
39. distance of the source of drinking
water from your house
1. Within premises
2. Outside premises but 250 1 100%
meters or less
3. 251 meters or more
4. Don't know
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8. 40. kind of toilet facility does the
household use
1. Water sealed flush to 1 100%
sewerage system/ septic tank
- own use
2. Water sealed flush to
sewerage system/ septic tank
- shared with other house
holds
3. Closed pit
4. Open pit
5. No toilet
6. Others pls specify
J. HOUSING
41. tenure status of the housing unit and
lot occupied by your household
1. Owner, owner-like 1 100%
possession of house and lot
2. Rent house/ -room
including lot
3. Own house, rent lot
4. Own house, rent-free lot
with consent of owner
5. Own house, rent-free lot
without consent of owner
6. Rent-free house and lot
with consent of
owner
7. Rent-free house and lot
without consent of owner
8. Other, pls specify
41. appliances in the household own any
of the following item
1. Radio / Radio Cassette 1
2. Television 1
3. CD/VCD/DVD player 1
4. Stereo/Component
5. Karaoke
6. Videoke
7. Refrigerator / Freezer
8. Electric Fan 1
9. Electric Iron 1
10. LPG Gas Stove/Range 1
11. Washing Machine
12. Microwave Oven
13. Personal Computer
14. Mobile Phone / 1
Cellular Phone
15. Landline Telephone
16. Air-conditioner
17. Sewing Machine
18. Car, Jeep,
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9. Motorcycle/other
motorized vehicles
Others (specify)
19. Radio / Radio
Cassette
20. Television
21. CD/VCD/DVD player
22. Stereo/Component
42. Construction materials used on the
WALLS of the house
1. Strong materials (concrete, 1 100%
brick, stone, wood,
galvanized iron, asbestos)
2. Light materials (bamboo,
sawali, cogon, nipa)
3. Salvaged/make-shift
materials
4. Mixed but predominantly
strong materials
5. Mixed but predominantly
light materials
6. Mixed but predominantly
salvaged materials
43. Construction materials used on the
ROOF of the house
1. Strong materials (concrete, 1 100%
brick, stone, wood, galvanized
iron, asbestos)
2. Light materials (bamboo,
sawali, cogon, nipa)
3. Salvaged/make-shift materials
4. Mixed but predominantly
strong materials
5. Mixed but predominantly
light materials
6. Mixed but predominantly
salvaged materials
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