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____ Class II_____ Class III_____ Class IV

Natural resources: forest_____ river____ lake_____ volcano______

sea_____ 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 ________________ 4. Graduate school _____________

2. High school_________________ 5. Never attended school ___________

3. College ___________________

IV. Epidemiologic Profile of the Community

Top 5 Causes of

MORTALITY

Number of Cases Actions Taken or Suggested Actions/Solutions

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) ________________