a) HEAD OF THE FAMILY -write the name of the recognized head of the household start with family

name, first name, middle initial (reminder: record in your jot-down notebook the full middle
name in cases you need to verify your clients of same family name and given name especially
among very common family names and given names ex. Jose Santos , Juan dela Cruz
ADDRESS– write the full address to include household number street municipality district and
or city

a) NAME -write the names of the household surnames first, then given name; in case of the wife,
indicate the maiden name; if several members with the same surname are listed in order, the
surname need not to be written names of the other members of household like servant and
boarders should be entered
b) RELATIONS TO THE HEAD OF THE FAMILY -indicate the relationship of the members to the head
of the household e.g. wife son daughter or mother
c) GENDER -enter M for male or F female
d) BIRTHDAY -enter the month, day and year (ex. January 9, 1978)
e) CIVIL STATUS -enter any of the following status
e.1) Single – person who are not and have never been married
e.2) Married – include couples living together as husband and wife with the benefit of legal
marriage
e.3) Common in law - includes couple living together as husband and wife without benefit of
legal marriage
e.4) Widowed – a person whose spouse is dead and who has not remarried
e.5) Separated /divorced – a person legally separated from his /her spouse or who is living
apart from his/her spouse because of marital discord or similar reasons of
of persons’ whose bond of marriage has been dissolved and can therefore
remarry
f) EDUCATIONAL ATTAINMENT – refers to the highest level completed in regular or formal system
of education Excluded are purely vocational courses such as dressmaking or carpentry
g) OCCUPATION– indicate the type of work and place or location of work

a) HOME
(a.1)Ownership
(a.2)Construction Materials
a.2.1) Light – refers to materials as bamboo, nipa, coconut leaves or cardboard
a.2.2) Mixed – refers to the combination of light material, wood and concrete
a.2.3) Strong – refers to concrete materials including the wall and the use of steel or iron as
(a.3) Bedroom(s)
(a.4)Lighting facilities
(a.5)General sanitization condition – write your impression of the general state of cleanliness
of the house Include objective data to support your impression
b) WATER SUPPLY
(b.1)Drinking water
b.1.1) Source
b.1.2)Distance from house – write the distance of the water source from the house in
meters If there is faucet connected to the public or private source inside the house
write ‘ inside the house’
b.1.3)Storage

c) KITCHEN
(c.1) Cooking facility – LPG gad stove, electric stove, charcoal, firewoods, butane gas
(c.2)Sanitary condition – describe briefly the state of cleanliness of the kitchen area support
your impression with objective data
(c.3)Drainage facility
c.3.1) None – when there is no drainage system; waste water from the kitchen flows
directly to the ground often times forming nearly permanent pool
c.3.2) Open drainage – waste water flows through the system of pipes to an open pit
or canal
c.3.3) Blind drainage – waste water flows a system of closed pipes to underground pit
or covered canal

d) WASTE DISPOSAL
(d.1) Refuse and Garbage
d.1.1) Container
d.1.2) Method of disposal
 hog feeding – garbage is used for hog feed
 open dumping – refuse and or garbage piled in a dumping place with or
without pit and with no soil covering
 open burning – regularly piles of refuse /garbage and later burned in an open
air
 burial in a pit – refuse / garbage is placed in a pit and covered when filled up.
 There is no intention to dig it up later for use as fertilizer.
 composting – refuse/ garbage is disposed with the used of incinerator
e) TOILET
(e.1) Type
e.1.1) Pail system – a pail or box is used to receive the excreta and disposed later
when filled up. This will include the “ballot” system when
excreta is wrapped in a piece of paper or plastic and thrown
away later.
e.1.2) Open privy pit – consist of a pit covered in a platform with a hole. The hole is
usually not covered. The platform may in its simplest
form consist only of two pieces of flat wood or bamboo
e.1.3) Closed privy pit –a pit privy with the hole over the platform or toilet floor is
provided and with cover
e.1.4) Bored hole latrine – consist of a deep but relatively narrow hole made with a
boring system
e.1.5) Overhung latrine – the toilet house is constructed over a body of water into
excreta is allowed to fall freely
e..1.6) Water sealed – bored hole latrine or any pit privy wherein water sealed
bowl is placed instead of simple platform hole
 (e.2)Septic tank
(e.3)Distance from house – write the distance of the toilet from the house in meters If
The toilet is inside the house write’ inside the house ‘
(e.4)Sanitary condition – describe briefly the state of cleanliness of the toilet

f) DOMESTIC ANIMAL
 Kind – write the kind of animal kept in the house and to those present in the
community
 Number – indicate the number for each kind of animal kept in the house and
community
 Where kept- indicate were domestic animal is kept e.g. tied in backyard

G) THE COMMUNITY IN GENERAL

 General sanitary condition – briefly describe the state of sanitation of the
immediate vicinity where the house is located Mentioned specific observation to
substantiate general impression
 Housing congestion – describes how close houses are from another house and the
space inside their house in reference to number of household members living
inside
 Recreational facilities – write the recreational facilities available in the community
e.g. basketball court reading center
 Availabilty of health care facilities – health facilities include government health
center and hospitals; private medical and dental practitioners; practicing nurses
and midwives
 Distance of house from nearest health care facility – give approximate distance

Name of the Interviewer: ______________________________ Date of Interview:_______________

Name of the respondent: ______________________________
Name of the head of the family:_________________________ (start with family name first name andmiddle initial)
Address: _________________________________

A. Family Structure and Characteristics

Name Relation Sex Age Birthday Civil Educational Occupation Religion Ethnic
to the Status Attainment Background
head
Describe in paragraph form:
 Type of family structure
 Dominant family members in terms of decision making in matters of health care
 General family relationship
B. Socio – Economic and Cultural factors – describe in paragraph form
C. Environmental Factors – See attached Checklist
D. Health Assessment of the members of the family – describe in paragraph form and give a
sample menu for nutritional assessment
E. Value placed on prevention of disease – describe in paragraph form