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Centro Escolar University

National Service Training Program (NSTP) Department

Makati*Manila

COMMUNITY PROFILE

SURVEY FORM

I. Socio-Demographic Profile:

Name (Optional) _________________________________ Age: _________Address :

________________________________________________________________

Specific Location : _____ Near the River _____ Near the Main Road

Place of Origin : ________________________ Number of Years of Stay ___________Present Addres:______________________________ Birthdate: ____________________

Place of Birth : ___________________________ Gender : _____ Male _____ Female

Civil Status: ______ Single _____ Married ______ Widow/er

Religion : _________________ Main Source of Income : ___________________Livelihood Skills : ______________________________________________________

Training Seminars Attended :Name Name of Training Organization Date

________________________________ __________________________

______________________________________ __________________________

______

________________________________ __________________________

______________________________________ __________________________

______________________________________ ________________________________

________________________________ __________________________

______________________________________ __________________________

______

________________________________ __________________________

______

II. Family Background of Respondent (R):

Gender : Male (M) Female(F) Civil Status Single (S) Married (M)

Highest Educational Attainment: Kindergarten(0) High School (2)

Elementary (l) College (3) Vocational (4)Name Gender Age Civil Status Relation to R Education

_________________ ____ ____ ______ ___________ _____

_________________ ____ ____ ______ ___________ _____

_________________ ____ ____ ______ ___________ _____

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_________________ ____ ____ ______ ___________ _____

_________________ ____ ____ ______ ___________ _____

_________________ ____ ____ ______ ___________ ______________________ ____ ____ ______ ___________ _____

_________________ ____ ____ ______ ___________ _____

_________________ ____ ____ ______ ___________ _____

III. Education

l. No. of Schools in the Barangay: 2. No. of Children in School

Private Public Private Public

Kindergarten ______ ______ ______ ______ Elementary ______ ______ ______ ______

High School ______ ______ ______ ______

College ______ ______ ______ ______

Vocational ______ ______ ______ ______ 2. What is your perception of education ?

Education is:_____ an opportunity to get a job

_____ an approach to address the problem of illiteracy

_____ a way of providing good future to the children_____ developing ones self-confidence and developing social responsibility

_____ Others, please specify _______________________________________

3.Dream(s) for Child(ren)

____ Finish studies____ Take a vocational course

____ Complete studies to get a job

____ Finish studies, get a job, and serve the family____ Others, pls. specify _________________________________________

IV. Livelihoodl. Means of Livelihood and System of Income

Name Means of Livelihood Income Method Used

________________ _______________ ______ _______________

________________ _______________ ______ _______________________________ _______________ ______ _______________

________________ _______________ ______ _______________

________________ _______________ ______ _______________2. Type of House

_____ Concrete _____ Made of Carton

_____ Made of Nipa _____ Made of Yero_____ Made of Wood _____ Others, pls. specify____________

3. No. of variety stores in the neighborhood _____

4. What do you perceive as personal blocks or blocks to develop yourself?

_____ lack of skills _____ lack of formal education

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______ lack of finances _____ lack of basic needs

______ Others, pls. specify ____________________________________________

V. Lifestyle

l. Type of House

_____ Owned _____ House owned, lot rented_____ Rented _____ Others, pls. specify_________________

_____ Not rented

2. If rented, amount of monthly rental______________________________3. No. of families staying in the house______________________________

4 Home Appliances

_____ T.V. ____ Cassette Recorder

_____Radio ____ Betamax/VHS_____ Electric Fan ____ Washing Machine

_____ Karaoke ____ Others, pls. specify__________________________

5. Common Family Expenses (Rate them 1 as the lowest and 8 as the highest)

_____ Food _____ Housing_____ Transportation _____ Recreation

_____Studies/School _____ Medicine_____ Electricity _____ Clothing

_____ Others, pls. specify ______________________________

6. Common Foods Served at HomeOften Seldom

_____ Meat ______ ___________

_____ Fish ______ ___________

_____ Vegetables ______ ___________ _____ Egg ______ ___________

_____ Others, pls. specify ______ ___________

7. Meals Taken by the Family_____Once _____ Thrice _____ Five Times

_____Twice _____ Four Times _____ Six Times, and More

8. Recreation of People in the Community_____ Bingo _____ Basketball ______ Billiards ____Dominos

_____ Mahjong _____ Volleyball ______ Card Games ____ Others, ______

VI. Healthl. Common Diseases/Illnesses

_____ Fever _____ Headache _____ Stomachache _____Toothache

_____ Colds _____ Nausea_____ Cough _____ Others, please specify: ____________________

2. Methods Used to Treat Illnesses/Diseases in the Family

____________________________________________________________________________________________

______________________________________________

3. Agencies Utilized to Attend to the Health Needs of People

Private Public

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___________________________________ _____________________________

___________________________________ _____________________________

___________________________________ ________________________________________________________________ _____________________________

4. Type of Toilet Used by the Family/Community

____________________________________________________________________5. Source of Drinking Water _______________________________________________

6. How do you dispose of your garbage?_____ Burning _____ Throwing _____ Through Garbage Collector

7. Suggestions/Recommendations to Improve the Health Condition of the People

__________________________________________________________________________________________________________________________________

_________________________________________________________________

VII. Existing Values, Beliefs, and Practices of People in the CommunityWhat are the beliefs and practices in the community in relation to the following:

A. Courtship _______________________________________________________

_______________________________________________________

B. Marriage ______________________________________________________________________________________________________________

C. Pregnancy______________________________________________________

_______________________________________________________

_______________________________________________________D. Burial _______________________________________________________

_______________________________________________________

VIII. Existing Association/Organization in the Community

1. Name of Association/Organization 2. Status

___________________________________ ___________________________________________________ ________________

___________________________________ ________________

___________________________________ ________________

IX. Problems in the Community

Problems Effects Action(s) Taken

_______________ _____________ ___________________________________________________ _____________ ____________________________________

_______________ _____________ ____________________________________

_______________ _____________ ___________________________________________________ _____________ ____________________________________

X. Suggestions/Recommendations to Resolve the Identified Problem(s)

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