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CPH Survey Tool-1

This document contains a survey instrument for collecting information on the socioeconomic status, home environment, health knowledge, healthcare access, and health status of families in Zamboanga City, Philippines. The survey collects demographic data on household members and their education levels. It also gathers information on economic status including occupations and incomes. Additional sections cover topics like home ownership, water/electricity access, sanitation facilities, health seeking behaviors, birth attendants, child immunizations and more. The purpose is to assess families' overall health and living conditions.

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36 views2 pages

CPH Survey Tool-1

This document contains a survey instrument for collecting information on the socioeconomic status, home environment, health knowledge, healthcare access, and health status of families in Zamboanga City, Philippines. The survey collects demographic data on household members and their education levels. It also gathers information on economic status including occupations and incomes. Additional sections cover topics like home ownership, water/electricity access, sanitation facilities, health seeking behaviors, birth attendants, child immunizations and more. The purpose is to assess families' overall health and living conditions.

Uploaded by

ariansofia1031
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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UNIVERSIDAD DE ZAMBOANGA Family No.

School of Allied Medicine


Tetuan ,Zamboanga City

COPAR SURVEY INSTRUMENT

A. FAMILY STRUCTURE/ SOCIO-CULTURAL

HOUSEHOLD MEMBERS AGE GENDER CIVIL STAT POSITION EDUC.ATTAINMENT

1._________________________ ______ ________ _________ __________ _________________


2._________________________ ______ ________ _________ __________ _________________
3._________________________ ______ ________ _________ __________ _________________
4._________________________ ______ ________ _________ __________ _________________
5._________________________ ______ ________ _________ __________ _________________
6._________________________ ______ ________ _________ __________ _________________
7._________________________ ______ ________ _________ __________ _________________
8._________________________ ______ ________ _________ __________ _________________

Type of Family:_______________________ Tribe:________________ Religion: _____________________


Length of Residency :__________________ Place of Origin: ________ Dialects:______________________

B.ECONOMIC STATUS

PRODUCTIVE MEMBERS OCCUPATIONAL STATUS OCCUPATION AVERAGE INCOME


(15-64 y.o) (E, SE, UE) (per day or mos.)

1._____________________ ______________________ _____________ _________________


2._____________________ ______________________ _____________ _________________
3._____________________ ______________________ _____________ _________________
4. _____________________ ______________________ _____________ _________________
5. _____________________ ______________________ _____________ _________________

C.HOME & ENVIRONMENT

Home Ownership: ____Owned _____Rented _____Rent free


Land Ownership: ____Owned _____Rented _____Rent free
Type of House: ____Concrete _____Wood _____Concrete wood ____Makeshift
Water Supply : ____Deep well _____Communal _____Distribution
Availability of Electricity: ____with electricity _____without electricity
Means of Cooking: ____Kerosene _____LPG _____Electric stove ____wood/charcoal
Food Sorage: ____with refrigirator _____with out ref.w/ cover ____ with out cover
Drinking Water Storage: ____with cover _____without cover
Garbage Dispossal: ____Compost pit _____ burning _____Open dumping ____Collected
Excreta Disposal : ____ pour flush _____Flush _____ Antipolo ____ ballot system
D. KNOWLEDGE ON THE CONCEPT OF HEALTH:

Health Seeking Behavior : ____Health Center ____Private Clinic ____Hospital ____Albularyo


Others (pls.specify):_______________
Source of Health Information: ____Health Center ____Hospital ____Media Others:____________

E. HEALTH CARE

Birth Attendant: ___________________________


Place of Delievery: ___________________________
Infant Feeding: ____Breastfeeding _____Bottle feeding _____Mix Milk:___________________
Weight of Children: ___________________________
Height of Children: ___________________________
Immunization of the Children:___BCG ___PENTA1 ___PENTA2 __PENTA3 __OPV1 ___OPV2 ___OPV3
Others :______________________

F. RESPONSIBLE PARENTHOOD

Family Planning Method Used: ____Natural ____Artificial


Specify specific method:_________________________
G. HEALTH STATUS OF CHILDREN:

NAMES OF CHILDREN Fully Partially Immunization Weight Height Common


Immunized Immunized Receives Illness
Experienced
1.

2.

3.

4.

5.

6.

BMI- BODY MASS INDEX CATEGORIES

 Under weight <18.5


 Normal weight 18.5- 24.9
 Overweight 25-29.9
 Obesity BMI of 30 or greater

 30-34.9 = grade 1 obesity


 35 to 39.9 = grade 2 obesity
 > 40 Grade 3 ( morbid obesity)

Formula /computation:

Mass (kg)
BMI = _______________
( Height (m))2

= mass (lb)
_______________X703
(height (in))2

Students NAME: ____________________________


Course /yr.sec:______________________________
Cph schedule:_______________________________

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