HOUSEHOLD SURVEY QUESTIONNAIRE
Thank you for taking the time to participate in this Community Needs Assessment. Your honest
responses will help us understand the real situation, concerns, and priorities of our community, so
we can work together in planning programs and services that truly respond to our needs.
1. Answer honestly and completely. There are no right or wrong answers-what matters most is your
personal experience and opinion
2. For questions with checkboxes (☐), place a ✔ or ☑ mark on the answer that best applies to you. You
may choose more than one answer if it says “Check all that apply.”
3. Use a pen or ballpen when answering. Please write clearly and legibly.
[Link]
HH ID NO. : ___________________________________
NAME OF THE HOUSEHOLD HEAD Date of Interview:
Lastname:
Firstname: Time Started: Time Ended:
Middlename: Ext. Complete Address:
B. DEMOGRAPHY
1. Numbers of family members in the household?
2. Number of females in the household?
3. Number of males in the household?
4. How many family members are married?
5. How many members in the household?
6. How many nuclear families in the household?
7. How many members of the household are working overseas?
Name of Age Sex Civil Birthdate Relationship Occupation/ Estimated Ethnicity Religion
members Status to the head Highest source of Monthly
of of the educational income Income
Household household attainment
C. HOUSING CONDITION
1. Type of housing 2. What type of material is 3. What type of material 4. What type of material is mainly used for
(Check all that mainly used for mainly used for construction of the floor? (Check all that
apply) construction of the roof? construction of wall? apply)
(Check all that apply) (Check all that apply)
( ) Single house ( ) Iron sheets
( ) Concrete ( ) Earth
( ) Duplex ( ) Nipa/cogon
( ) Wood ( ) Cement screed
( ) Concrete
( ) Cement Blocks ( ) Concrete
( ) Wood
( ) Half concrete half ( ) Tiles
( ) Others,
wood ( ) Brick
specify:
( ) Stone
____________
( ) Wood
( ) Others, please specify:
WATER SYSTEM TYPE OF TOILET SOURCE OF ELECTRICITY
FACILITY
5. What is the 6. What is the source 7. What type of toilet 8. What source of electricity does the
household’s MAIN of water supply for facility household household use? ( check all that apply)
source of water for cooking, laundry and used?
DRINKING? (Check all bathing (Check all that apply)
that apply) (Check all that apply)
( ) Flush toilet to
( ) Direct from tap ( ) Direct from own sewer system ( ) Electric company
( ) household, yard or faucet ( ) Flush toilet to ( ) Generator
standpipe) ( ) Shared faucet in septic tank ( ) Solar
( ) Household storage community ( ) Pit latrine ( )Battery
tank or barrel ( ) Own deep well ( ) water sealed, ( )others, specify:
( ) Well ( ) Shared deep well sewer septic tank,
( ) Rain water collection ( ) Protected spring used exclusively
( )River/creek/stream ( )Unprotected spring by household
( ) Spring ( ) Lake, river, streams ( ) water sealed,
( )Purchase bottled ( ) Bottled water sewer septic tank,
water ( )Rain water collection shared with other
household
( ) Others:
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D. EDUCATION AND LITERACY E. ECONOMIC CONDITION
9. How many household members are currently 18. What is the other source of income of
attending school? the household?
10. Are all school-age children in your household
attending school? ☐ Yes ☐ No ( ) Farming/
If no, what are the reasons? gardening
( ) Fishing
☐ Financial problems ( ) Poultry or livestock
☐ Distance/lack of school raising
☐ Lack of documents ( ) Wholesale/ retail store
☐ Others: ___________ ( ) Dressmaking/ tailoring/weaving
( ) Crafts making
11. What educational support does your family need?
( ) Transportation services (tricycle
☐ Scholarships ☐ School supplies ☐ ALS ☐ Skills Training driver, habal- habal driver, etc.)
☐ Others: ___________ ( ) Construction worker
F. HEALTH CONDITION ( ) Others, specify:
12. Do you have access to health services in your area? ☐ Yes 19. What are the appliances and gadgets owned by
☐ No the household?
13. What are the common ailments of the household for the past ( ) Radio
12 months? ( ) Television set
( ) Allergies ( ) CD/DVD/VCD player
( ) Colds and flu ( ) Component/ stereo set
( ) Diarrhea ( ) Landline/wireless telephone
( ) Headaches ( ) Cellular phone
( ) Stomach Aches ( ) Personal computer (desktop, laptop,
( ) netbook, and others)
14. What health services or assistance would be most helpful to ( ) Refrigerator/ freezer
your family? ( ) Cooking range
( ) Washing machine
( ) Car/jeep/van
15. What are the serious ailments of the household? ( ) Motorcycle/ tricycle
( ) Motorized boat/ bangka
( ) Heart Disease ( ) Electric fan
( ) Hypertension ( ) Flat iron
( ) Stroke ( ) Air conditioner
( ) Respiratory illness ( ) Sewing machine
( ) Chronic obstructive pulmonary disease
( ) Cancers 20. What are the ownership and control of resources
( ) Diabetes of the household?
( ) Alzheimer’s disease
( ) Pig pens
( ) Poultry
16. Is there any member of the 17. Is there any member of
( ) Rice mill
household are malnourished? the household had a
( ) Backyard vegetable garden
physical check-up for the
( ) Fishpond
( ) yes, how many past 12 months?
( ) Others:
( ) None
( ) Yes
( ) No, Why?
G. POLITICAL
21. How many registered voters are there in the household?
22. Do the household members participate in the choosing local leaders in the community? ( ) yes ( ) no
G. DISASTER PREPAREDNESS AND CALAMITY EXPERIENCE
23. Has your household been affected by any calamity in the past 3 years? ( ) yes ( ) no
24. If yes, what calamities did your household experienced? ( )Typhoon ( ) Flood ( ) Drought ( ) Earthquake ( ) Landslide ( )
Fire ( ) Armed Conflict, ( ) others, specify _________________
25. What damages or losses did your family experience during the calamity? (Check all that apply)
☐ Damage to house ☐ Loss of livelihood/income
☐ Injury or illness ☐ Loss of livestock or crops
☐ Displacement (evacuation) ☐ Others: _____________________
26. Did your household receive any assistance after the calamity? ( ) yes ( ) no
27. Are you aware of any disaster preparedness plans or trainings in your community? ( ) yes ( ) no
28. Does your household have a basic emergency kit or disaster preparedness plan?
☐ Yes
☐ No
☐ We want to learn how to prepare
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H. DISASTER PREPAREDNESS I. WASTE MANAGEMENT
29. What support or programs would help your family
be more prepared for future calamities?
30. What is the system of garbage disposal by the
☐ Disaster preparedness training /seminar household?
☐ First aid and basic life support training ( ) Garbage Collection ( ) Pit with cover
☐ Emergency kits or supplies (food, water, flashlight, ( ) Burning ( ) Pit without cover
etc.),
☐ Evacuation plan orientation ( ) Composting ( ) Throwing garbage
☐ Construction or repair of evacuation centers ( ) Recycling in the river
☐ Community drills or simulation activities ( ) Waste Segregation ( ) Others:
☐ Others (please specify):
____________________________________________
J. PROGRAMS
31. For the past 12 months, did any member of your 32. Who implemented the program?
household receive or avail any of the following (Based from Q31)
programs?
( ) Sustainable Livelihood Programs (DSWD) ( ) National
( ) Food/Cash for work
( ) Congress/District
( ) Social Pension for Indigent Senior Citizen
( ) Pantawid Pamilyang Pilipino Program (4Ps) ( ) Province
( ) Agrarian Reform Community Development ( ) Barangay
Program ( ) City/Municipality
( ) Training for work Scholarship Program ( ) I don't know
( ) Health assistance ( ) Private Organizations/NGOs
( ) Supplemental Feeding ( ) Others, specify
( ) Educational or Scholarship Program
( ) Skills or Livelihood Training Program
( ) Others, specify:
K. COMMUNITY NEEDS IDENTIFICATION
33. As a resident, identify (5) five current needs/ problems. (1-5) from most priority to least priority.
1. _____________________________________________________
2. _____________________________________________________
3. _____________________________________________________
4. _____________________________________________________
5. _____________________________________________________
34. What specific actions or improvements do you think are needed to address needs or problems you
identified in question (24)?
35. What services or amenities are currently lacking in your community?
36. What additional facilities or resources do you think are needed in your Community to improve the
quality of life for this resident?
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Oath of Willingness and Consent to Use Information
I, the undersigned, acknowledge that I have participated in this community needs assessment
voluntarily and with full understanding of its purpose. I understand that the information I have provided
in this questionnaire will be used to help assess the current situation of our community, identify our
needs and concerns, and guide the development of appropriate programs, projects, and services for
our benefit.
I am aware that the data collected through this assessment may be used by the organizing team,
partner government agencies, and supporting organizations as a basis for planning interventions that
are responsive to the real issues affecting our community. These may include, but are not limited to,
programs on livelihood, education, health, safety, disaster preparedness, and community
empowerment.
I willingly give my consent for the use of my responses, with the understanding that all information
will be treated with utmost confidentiality and will not be used to cause harm, discrimination, or
disadvantage to me or my family. I trust that the information gathered will be used solely for the
purpose of promoting the welfare and development of our community.
I understand that my participation is entirely voluntary, and I may choose not to answer any question
that I am not comfortable with. I also understand that I can withdraw from this assessment at any time.
By signing below, I declare that I have freely and honestly provided the information in this form, and
that I give my full consent to its use in accordance with the above-stated purpose.
Signature / Thumbmark: _______________________________
Printed Name : _______________________________
Date: _______________________________
Zone / Purok: _______________________________
Contact Number: _______________________________
Barangay: ________________________________
_______________________________
Name and Signature of the Enumerator
Date: ______________
Noted by:
_______________________________________
Area Field Instructor
Date: ______________
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