Questionnaire
Saint Gabriel College, Inc.
School of Technical Vocational Education
National Service Training Program
CIVIL WELFARE TRAINING SERVICE
COMMUNITY ASSESSMENT PROGRAM
Family Socio-Economic Profile
Barangay: ___________________________________________________________ Date: ____________________
Place: ______________________________ NSTP Student: _____________________________________________
A. PROFILE OF THE RESPONDENTS:
FATHER
Name: _______________________________________________________________ Age: ____ Gender: _____
Marital Status: ______________________ Highest Educational Attainment: ____________________________
Religious Affiliation: __________________________________ Occupation: ____________________________
Monthly Income: ____________________ Job Status: Permanent/ Regular/Contractual
B. MEMBER OF THE FAMILY
Number of Children: ______________
A. PROFILE OF THE RESPONDENTS:
MOTHER
Name: _______________________________________________________________ Age: ____ Gender: _____
Marital Status: ______________________ Highest Educational Attainment: ____________________________
Religious Affiliation: __________________________________ Occupation: ____________________________
Monthly Income: ____________________ Job Status: Permanent/ Regular/Contractual
B. MEMBER OF THE FAMILY
Number of Children: ______________
Gender Civil Status Highest Still studying (State Occupation Job Status Monthly
Educational what particular Income
Attainment course and year)
1
2
3
4
5
6
7
8
9
10
C. EXTENDED FAMILY
Please Check:
____________ Mother
____________ Father
____________ Brother
____________ Sister
D. EXPENDITURES
How much your family monthly expenses on the following:
a. Food ________________________ e. Education of the children _______________________
b. Water _______________________ f. Fare in going to work ___________________________
c. Electricity ____________________ g. Fare of the student ____________________________
d. House rental (if renting) _________ h. Total Expenditures _____________________________
E. HEALTH
1. Do you have members of the family suffering from any ailment? Please check.
(answerable by: Mother, father, brother, sister, son, and daughter)
High blood (Who?) _______________________________________________
Heart Disease (Who?) _____________________________________________
Diabetes (Who?) _________________________________________________
Pneumonia (Who?) _______________________________________________
Bronchitis (Who?) ________________________________________________
Etc. (please specify) _______________________________________________
2. Do you practice family planning? YES / NO. Since when? _________________
3. Where do you consult when the member of the family get sick?
a. Faith Healer c. Public Health Center
b. Quack Doctor d. Private Clinic / Hospital
F. WATER and SANITATION
1. Source of Water:
Please check
________ Metro Kalibo Water District _______ Artesian Well
________ Well _______ River
________ Other (Please Specify) _______________
2. Do you have a comfort room? YES / NO. What type?
Flush type _______ No Flush ______
Thrown in the water _______ Other (Please Specify) ______________________
G. OTHER INQUIRES
1. Have you experienced any domestic violence in the family? YES / NO.
2. How many members in the family who are already voters? ___________
3. Were you able to vote during election? YES / NO.
4. What are the present problems you are encountering in your community?
__________________________________________________________________________________
5. What are possible solution you recommend to address the issues/problem in your community?
__________________________________________________________________________________
__________________________________________________________________________________
