Questionnaire on Community Health Nursing
Name of the community/ barangay_________________________________
Location of the community________________________________________
1.
Size and Type of Community
Land area: _______
Geographic unit: barrio____ village______ barangay_____
Type of community:
rural_____
urban_______ rurban(suburbs)________
Agricultural_______ industrial________ shanty town______
Informal settlers/squatters_________
Socio-economic class:
Class I____
Natural resources:
forest_____ river____ lake_____ volcano______
sea_____
Class II_____ Class III_____ Class IV
ocean_____ mountain_____ tourist spot_____
II. Demographic profile of the Community
Total Population________
Year when census was taken___________
Population density _____________
sex ratio (male to female) _____________
Age structure (percentage of the population)
0-1year old _________
Widow________
Separated__________
Single parent_________
Widower _______
Divorce___________
Married_________
Annulled________
Total number of families/household_________ Average family size________
Top three ethnic groups according to number or predominance in the community (like
Visayans, Tagalog, Ilokanos, Kapangpangans, Bicolanos, Aetas and etc.).
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
Top three predominant religions/religious groups/sectors, etc)
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________
III. Socio-economic Data
Top three main occupation/industries
1. _____________________________________________
2. _____________________________________________
3. ______________________________________________
Other sources of income or community livelihood programs
1._________________________________________________
2. _________________________________________________
Average Family Income: check the bracket and indicate percentage of the population
with corresponding monthly family income.
Below 5,000.00 php
__________________________
Above 5,000.00-10,000.00 php.
__________________________
Above 10,000.00-15,000.00 php
__________________________
Above 15,000.00-20,000.00 php ___________________________
Above 20,000.00-30,000.00 php ____________________________
Unemployment rate___________________________
Percentage of population below poverty level_______________________
Percentage of population who completed;
1. Elementary ________________
2. High school_________________
3. College ___________________
4. Graduate school _____________
5. Never attended school ___________
IV. Epidemiologic Profile of the Community
Top 5 Causes of
Number of Cases
Actions Taken or Suggested Actions/Solutions
MORTALITY
Top 5 Causes of
MORBIDITY
Number of Cases
Actions Taken or Suggested
Actions/Solutions
V. Environmental Health Facilities
Water Supply
Source of supply ____________________
Type of water supply: owned (pose, jetmatic) __________ Bought _____
Shared _________ Others, specify _________
Quality of water________________________________
Waste disposal system: Check the appropriate and indicate the percentage.
Flush _________ Wrap and throw________ Water sealed__________
Pit privy_______
Others, Specify_________________
Refuse/garbage disposal: Check the appropriate answer and indicate the percentage.
Collected___________
Open dumping_____________
Waste segregation_________
Burning_______________
Feeding leftover to animals_________
Burying_________________
Balot tapoin in the river/sewer ____________ Others, specify ___________
Housing: check the answer and indicate the percentage.
Wood ____________
Concrete _________________
Makeshift_______________ Mixed (wood & concrete) ________________
