Identification

Province *

City *

Zone *

Barangay *

Purok/Sitio *

Street name *

House Number *

Household Identification Number *

Location *

Latitude

Longitude

Name of respondent *

time started *

time finished *

Date Field

Name and signature of enumerator *

Name and signature of field editor/coordinator *

Housing Characteristics

In what type of building does the household reside? *

How many bedrooms does this housing unit have? *

What type of construction materials are the roof made of? *

What type of construction materials are the outer walls made of? *

Household Characteristics

How many household members are overseas workers? *

How many nuclear families are there in the household? *

Is any of the member of the household pregnant?  *

Yes

Is any member of the household a solo parent?  *

Yes

Is any member of the household disabled? *

Yes

Demography

How many members are there in the household, including OFWs? *

Who is the head of the household? *

Who are the other members of the household? *

Surname *

First Name *

middle name *

in which nuclear family do they belong *

What is their relationship to the head of the household

Sex

In what month, day and year were they born? *

Age *

Was their birth registered with the civil registry office? *

Yes

(For 10 and above) What is their marital (Civil) status?

What is their ethnicity by blood? *

(If there is an OFW and is age 10 and above) are they an overseas worker?

Yes

(For 3 years old and above) Where were they residing 3 years ago? *

Same address now

Other

Are they currently attending school? *

Yes

If yes, what grade or year are they currently attending?

Where do they attend school?

Public

Private

If college graduate, what is his/her course?

(For 5 years old and above) Can they read and write a simple message in any language or dialect? *

Yes

(For 15 years old and above) Are they a registered voter? *

Yes

If yes, did they vote in the last election *

Yes

Don't know

If no, did they do any work for at least 1 hour during the past week? *

Yes

If no, did they do any work for at least 1 hour during the past week? *

Yes

Although they did not work, did they have a job or business during the past week? *

Yes

If no, did they look for work or try to establish business during the past week? *

Yes

If no, why did they not look for work? *

Tired/believes no work is available

Awaiting results of previous job application

Temporary illness/disability

Bad weather

Waiting for rehire/job recall

Too young/old or retired/permanent disability

Household, family duties

Schooling

Other

When was the last time they looked for work? *

Within last month

One to six months

More than

Other

If they do any work during the past week, what was their primary occupation during the past week? *

In what kind of industry did they work during the past week? *

what is their nature of employment *

Permanent job/business/unpaid family work

Short-term or seasonal or casual job/business/unpaid family work

Worked for different employers or customers on day-to-day or week-to-week basis

Other

What was their normal working hours per day during the past week? *

What was their total number of hours worked during the past week? *

did they want more hours of work during the past week? *

Yes

Other

did they look for additional work during the past week *

Yes

Other

was this their first time to look for work or try to establish a business *

Yes

Other

what have been they doing to find work *

Registered in public employment agency

Registered private in employment agency

Approached relatives or friends

placed or answered advertisments

Searched and applied online

Other

How many weeks have they been looking for work? *

what is their class of worker? *

Working for private household

Working for private businesses/establishment/farm

Working for government/government corporation

Self-employed with no paid employee

Employer in own family-operated farm or business

Working with pay on own family-operated farm or business

Working without pay on own family-operated farm or business

Other

Had opportunity for work existed last week or within two weeks, would they been available? *

Yes

Were they willing to take up work during the past week or within 2 weeks *

Yes

In the past 12 months, how much total salary/wages did they receive? (Do not include salary of household members who are OFW and housemaids/boys) *

Are they a member of SSS or GSIS *

Yes, SSS

Yes, GSIS

Yes, both

Health and other characteristics of household members

Is the interviewee pregnant *

Yes

Are they a solo parent taking care of a child/children *

Yes

Do they have any physical or mental disability *

Yes

(For 60 years old and above) Do they have a senior citizen's ID? *

Yes

Other

Have they been a victim of crime in the past 12 months? *

Yes

Other

If yes, what crime/s was/were they a victim of? *

Theft

Robbery

Rape

Physical injury

Carnapping

Cattle rustling

Other

Where did the crime happen *

Within the barangay

Outside the barangay but within municipality/city

Outside the municipality/city but within province

Outside the province

(For 5 years old and below) Nutritional status of children 0-5 years old and date of record of barangay nutrition scholar *

Above normal

Normal

Below normal (moderate)

Below normal (severe)

COMMUNITY-BASED MONITORING SYSTEM

Identification

Housing Characteristics

Household Characteristics

Demography

Health and other characteristics of household members

Water and Sanitation

Waste Management