CBMS FORM 2

Approval Number : PSA-2142-03

Expiry Date : 31 July 2022

2021 PILOT COMMUNITY-BASED MONITORING SYSTEM

HOUSEHOLD PROFILE QUESTIONNAIRE
Dear Sir/Madam:

The Philippine Statistics Authority (PSA) is collecting information from every household in the country using the Community-Based Monitoring
System or CBMS. The CBMS aims to gather information about your household on different dimensions such as health, nutrition, water,
sanitation, shelter, education, income, employment, security, participation, and disaster-preparedness. The data collected will be used by your
city/municipality and national government agencies to craft evidence-based policies and programs for the development of the community.

The PSA highly encourages your participation and cooperation in the CBMS activity since data collected will be used to target beneficiaries of
social and economic development programs of the government, among its other goals. However, participation in the CBMS is purely voluntary.
If you intend to participate in the activity, it is assured that the data you provide shall be utilized in the betterment of your community. In addition,
there is no right or wrong answer in accomplishing this questionnaire, but we encourage you to provide truthful and complete answers.

Please be informed that all information shared are strictly confidential pursuant to Section 10 (Confidentiality of Information) of Republic Act (RA)
No. 11315 or the CBMS Act and Section 8 (Confidentiality) of RA No. 10173 or the Data Privacy Act of 2012 and will not be used against you or
to any of your household members for taxation, investigation, or law enforcement purposes.

If you have inquiries, you may contact PSA at (02) 8376-1909. You may also send us a message through the following e-mail addresses:
[email protected] and [email protected].
Thank you very much.
Mapa Claire Dennis Sioson
2021.09.06 12:38:15 +08'00'
CLAIRE DENNIS S. MAPA, Ph.D.
Undersecretary
National Statistician and Civil Registrar General

CERTIFICATION GEOGRAPHIC IDENTIFICATION

I hereby certify that the data set forth BOOKLET OF BOOKLETS
herein were personally obtained/reviewed
by me and in accordance with the PROVINCE
instructions given by the PSA.

CITY/MUNICIPALITY
_______________________________
ENUMERATOR
SIGNATURE OVER PRINTED NAME BARANGAY

_______________________________
SITIO/PUROK
DATE ACCOMPLISHED
(MM/DD/YYYY)
ENUMERATION AREA NUMBER ········································
_______________________________
TEAM SUPERVISOR
SIGNATURE OVER PRINTED NAME BUILDING SERIAL NUMBER ····························································

_______________________________ HOUSING UNIT SERIAL NUMBER ····················································

DATE ACCOMPLISHED
(MM/DD/YYYY)
HOUSEHOLD SERIAL NUMBER ·······················································
_______________________________
CBMS AREA SUPERVISOR
SIGNATURE OVER PRINTED NAME LINE NUMBER OF THE RESPONDENT ···························································

_______________________________ CONTACT NUMBER ·························································

DATE ACCOMPLISHED
(MM/DD/YYYY)
EMAIL ADDRESS
_______________________________
CO/RSSO/PSO SUPERVISOR NAME OF THE HOUSEHOLD HEAD
SIGNATURE OVER PRINTED NAME
Last Name First Name, Suffix, Middle Initial
_______________________________ ADDRESS
DATE ACCOMPLISHED
(MM/DD/YYYY) HOUSE/BUILDING NUMBER AND STREET OR SITIO/PUROK NAME

INTERVIEW RECORD
VISIT NUMBER 1 2 3 SUMMARY OF VISIT
DATE
MM/DD/YYYY NUMBER OF VISIT/S MADE
TIME BEGAN
RESULT OF FINAL VISIT
(HH:MM)
TIME ENDED NUMBER OF HOUSEHOLD MEMBERS
(HH:MM)
NUMBER OF MALES
RESULT OF VISIT
CODES FOR THE RESULT OF VISIT NUMBER OF FEMALES
1 COMPLETED
2 REFUSED NUMBER OF NUCLEAR FAMILIES
3 OTHERS
4 CALLBACK (WITH APPOINTMENT DATE) ENUMERATOR'S CODE
5 CALLBACK (NOT YET COMPLETED)
MODE OF DATA COLLECTION
APPOINTMENT FOR NEXT VISIT
VISIT NUMBER 1 2 1 COMPUTER-ASSISTED PERSONAL INTERVIEW
DATE 2 COMPUTER-AIDED WEB INTERVIEW
MM/DD/YYYY 3 PAPER AND PENCIL PERSONAL INTERVIEW
TIME 4 SELF-ADMINISTERED QUESTIONNAIRE
(HH:MM)
CBMS Form 2 HPQ 1 of 40 Version as of 30/08/2021
A. DEMOGRAPHIC CHARACTERISTICS
FOR ALL HOUSEHOLD MEMBERS
Who is the household head? What is (NAME)’s In which What is Is (NAME) In what month, day and What is (NAME)'s age
Who are the other members of the relationship to the nuclear family (NAME)’s male or year was (NAME) born? as of last birthday
household usually residing here as of head of this does (NAME) relationship to female? October 1, 2021?
October 1, 2021? household? belong? the head of the
nuclear family?
L
I
N
E

N
U ORDER OF LISTING:
M • Head
B • Spouse of the head 1 Family Head
E
• Never-married children of the head/ 2 Spouse
R
spouse, from the oldest to the youngest 3 Partner Month (MM)
• Ever-married children of the head/ 4 Son Day (DD)
spouse and their families, from the 5 Daughter Year (YYYY)
oldest to the youngest 6 Brother
• Other relatives of the head 7 Sister M M D D
• Nonrelatives of the head (SEE CODES 8 Father 1 Male Y Y Y Y
BELOW) 9 Mother 2 Female
(01) (02) (03) (04) (05) (06) (07)

____________________
FIRST NAME, SUFFIX,
1 MIDDLE INITIAL 0 1 1
____________________
LAST NAME

____________________
FIRST NAME, SUFFIX,
2 MIDDLE INITIAL

____________________
LAST NAME

____________________
FIRST NAME, SUFFIX,
3 MIDDLE INITIAL

____________________
LAST NAME

____________________
FIRST NAME, SUFFIX,
4 MIDDLE INITIAL

____________________
LAST NAME

____________________
FIRST NAME, SUFFIX,
5 MIDDLE INITIAL

____________________
LAST NAME

____________________
FIRST NAME, SUFFIX,
6 MIDDLE INITIAL

____________________
LAST NAME
CHECK FOR PERSONS NOT YET INDICATOR FOR
(02) RELATIONSHIP TO THE HOUSEHOLD HEAD
LISTED ADDITIONAL BOOKLET
Are there any other persons such as OFWs, Are there more than six (6) 01 HEAD 15 BROTHER
kasambahay, babies/infants/small children members in this household? 02 SPOUSE 16 SISTER
whom we have not listed? 03 SON 17 BROTHER-IN-LAW
04 DAUGHTER 18 SISTER-IN-LAW
05 STEPSON 19 UNCLE
06 STEPDAUGHTER 20 AUNT
1 Yes, ADD TO THE 1 Yes, USE 07 SON-IN-LAW 21 NEPHEW
HOUSEHOLD ADDITIONAL 08 DAUGHTER-IN-LAW 22 NIECE
MEMBER LIST BOOKLET
09 GRANDSON 23 BOARDER
2 None 2 No 10 GRANDDAUGHTER 24 DOMESTIC HELPER
11 FATHER 25 OTHER RELATIVE
12 MOTHER 26 NONRELATIVE
13 FATHER-IN-LAW
14 MOTHER-IN-LAW

Version as of 30/08/2021 2 of 40 CBMS Form 2 HPQ

A. DEMOGRAPHIC CHARACTERISTICS
FOR ALL HOUSEHOLD MEMBERS
Was (NAME)’s Is (NAME) What is (NAME)’s What is (NAME)’s Was (NAME) Has (NAME) What is Was (NAME) What is
birth registered single, married, ethnicity by descent/ religious affiliation? issued a undergone Step (NAME)'s issued a city / (NAME)'s
with the Local Civil common law/live blood relation/ National ID/ 2 Registration PhilSys municipal LGU ID
Registry Office? -in, widowed, or consanguinity? PhilID? for the National Number LGU ID? number?
divorced/ ID/PhilID? (PSN)?
L separated/ Is he/she a/an ____? (NOTE TO EN:
I annulled? Step 2:
N Validation of
E demographic
data such as
N biometric
U information, iris
M scan,
B fingerprints and
E
front-facing
R
FOR MENTION THE photograph)
CHILDREN PREDOMINANT/
“0” TO “9” COMMON 1 Yes 1 Yes
YEARS OLD, INDIGENOUS 1 Yes, go to 2 No, go to 2 No, go to
1 Yes WRITE CODE PEOPLES (IP) OR 12.3 13.1 14
2 No “1” (SINGLE) NON-IP GROUPS IN 2 No 8 Don't Know, 8 Don't Know,
8 Don't Know IN THE BOX. THE AREA. 8 Don't Know go to 13.1 go to 14
(08) (09) (10) (11) (12.1) (12.2) (12.3) (13.1) (13.2)
____________ ____________
SPECIFY SPECIFY
1
_________ ________

____________ ____________
SPECIFY SPECIFY
2
_________ ________

____________ ____________
SPECIFY SPECIFY
3
_________ ________

____________ ____________
SPECIFY SPECIFY
4
_________ ________

____________ ____________
SPECIFY SPECIFY
5
_________ ________

____________ ____________
SPECIFY SPECIFY
6
_________ ________

(09) MARITAL STATUS

1 SINGLE
2 MARRIED
3 COMMON LAW/LIVE-IN
4 WIDOWED
5 DIVORCED
6 SEPARATED
7 ANNULLED
8 UNKNOWN

CBMS Form 2 HPQ 3 of 40 Version as of 30/08/2021

A. DEMOGRAPHIC CHARACTERISTICS
FOR 60 YEARS
FOR 10 YEARS OLD AND OVER FOR ALL PERSONS 5 YEARS OLD AND OVER
OLD AND OVER

Is (NAME) a solo Does (NAME) Does (NAME) have The following questions ask about difficulties a person may have
parent taking have a Solo a Senior Citizen ID? doing certain activities because of a HEALTH PROBLEM.
care of a child/ Parent ID?
children? Does (NAME) have any difficulty/problem in…?
L
I
N
E (NOTE TO EN:
Parents with
N unemployed,
U unmarried
M children less than
B 18 years old or a b c d e f
E children 18 years
R Seeing, Hearing, even Walking or Remembering or Self-caring Communicating
old and above
even if wearing if using hearing climbing steps Concentrating (such as using his/her usual
with disability are
glasses aid washing all over (customary
considered as
or dressing) language)
solo parent) 1 Yes 1 Yes
2 No 2 No
8 Don't Know 8 Don't Know
1 Yes
2 No, go to 16
(14) (15) (16) (17)

(17) MENTION THESE CATEGORIES:

1 NO, no difficulty
2 YES, some difficulty
3 YES, a lot of difficulty
4 Cannot do it at all

Version as of 30/08/2021 4 of 40 CBMS Form 2 HPQ

B. MIGRATION
Now we will ask about your household member's migration experience and whether there are Overseas Filipino in this household.
FOR 5 YEARS OLD AND OVER FOR 15 YEARS OLD AND OVER
In what province In what province What is Where was (NAME) What is Is When did For how Where is In the past
and city/ and city/municipality (NAME)’s residing six (6) (NAME)’s (NAME) (NAME) (last) many (NAME)’s twelve (12)
municipality did or country did reason for months ago? reason for an leave the months did country of work/ months,
(NAME)'s mother (NAME) reside five moving moving six Overseas Philippines? (NAME) study/visit? how many
reside at the time of (5) years ago? five (5) (6) months Filipino? stay/intend times does
L
(NAME)'s birth? years ago ago as (as of to stay (NAME)
I
as compared to October abroad (last send
N
E compared current usual 1, 2021) time)? money?
to current residence?
N usual Overseas
U residence? Filipino
M Indicator
B 0000 Same Current 0000 Same Current
E 0000 Same Current City/Municipality, go City/Municipality, go
R
City/Municipality to 04 to 06
9998 Don't Know 9998 Don't Know 9998 Don't Know (No. of
2 digits for Province 2 digits for Province 2 digits for Province (MM/YYYY) Months)
2 digits for City/ 2 digits for City/ (SEE 2 digits for City/ (SEE Code 98 Don't Know
Municipality Municipality CODES Municipality CODES 3,4,5,6, 9998 Don't Know 98 Don't 98 Don't
4 digits for Country 4 digits for Country BELOW) 4 digits for Country BELOW) go to 09 Know Know

(01) (02) (03) (04) (05) (06) (07) (08) (09) (10)

________________ ________________ ________________ ____________

PROVINCE PROVINCE PROVINCE COUNTRY
________________ ________________ ________________
1 CITY/MUNICIPALITY CITY/MUNICIPALITY CITY/MUNICIPALITY

PROV CITY/MUN PROV CITY/MUN PROV CITY/MUN COUNTRY CODE

________________ ________________ ________________ ____________

PROVINCE PROVINCE PROVINCE COUNTRY
________________ ________________ ________________
2 CITY/MUNICIPALITY CITY/MUNICIPALITY CITY/MUNICIPALITY

PROV CITY/MUN PROV CITY/MUN PROV CITY/MUN COUNTRY CODE

________________ ________________ ________________ ____________

PROVINCE PROVINCE PROVINCE COUNTRY
________________ ________________ ________________
3 CITY/MUNICIPALITY CITY/MUNICIPALITY CITY/MUNICIPALITY

PROV CITY/MUN PROV CITY/MUN PROV CITY/MUN COUNTRY CODE

________________ ________________ ________________ ____________

PROVINCE PROVINCE PROVINCE COUNTRY
________________ ________________ ________________
4 CITY/MUNICIPALITY CITY/MUNICIPALITY CITY/MUNICIPALITY

PROV CITY/MUN PROV CITY/MUN PROV CITY/MUN COUNTRY CODE

________________ ________________ ________________ ____________

PROVINCE PROVINCE PROVINCE COUNTRY
________________ ________________ ________________
5 CITY/MUNICIPALITY CITY/MUNICIPALITY CITY/MUNICIPALITY

PROV CITY/MUN PROV CITY/MUN PROV CITY/MUN COUNTRY CODE

________________ ________________ ________________ ____________

PROVINCE PROVINCE PROVINCE COUNTRY
________________ ________________ ________________
6 CITY/MUNICIPALITY CITY/MUNICIPALITY CITY/MUNICIPALITY

PROV CITY/MUN PROV CITY/MUN PROV CITY/MUN COUNTRY CODE

(03) and (05) REASON FOR MOVING (06) OVERSEAS FILIPINO INDICATOR
01 SCHOOL 09 TO LIVE WITH PARENTS 1 OVERSEAS FILIPINO WORKER (OFW) WITH CONTRACT
02 EMPLOYMENT/JOB CHANGE/JOB 10 TO JOIN SPOUSE/PARTNER 2 OTHER OFW WITH NO CONTRACT
RELOCATION 11 TO LIVE WITH CHILDREN 3 EMPLOYEES IN PHIL. EMBASSY, CONSULATES & OTHER MISSIONS,
03 FAMILY BUSINESS SUCCESSION 12 MARRIAGE GO TO 09
04 FINISHED CONTRACT 13 DIVORCE/ANNULMENT 4 STUDENTS ABROAD, GO TO 09
05 RETIREMENT 14 HEALTH-RELATED REASONS 5 TOURIST, GO TO 09
06 HOUSING-RELATED REASON 15 PEACE AND SECURITY 6 OTHER OVERSEAS FILIPINO NOT ELSEWHERE CLASSFIED, GO TO
07 LIVING ENVIRONMENT 09
99 OTHERS, SPECIFY: __________
08 COMMUTING-RELATED REASONS 7 RESIDENTS (PHILIPPINES), GO TO SECTION C

CBMS Form 2 HPQ 5 of 40 Version as of 30/08/2021

C. EDUCATION AND LITERACY
The next set of questions pertains to the education, literacy and skills training attended by each of the household members.
FOR 5 YEARS OLD AND OVER FOR 3 TO 24 YEARS OLD FOR 15 YEARS OLD AND OVER

L Can (NAME) What is (NAME)'s Is (NAME) In which What grade or year is Why is (NAME) Is (NAME) a Is (NAME) What skills
I read and highest grade currently school is (NAME) currently not attending graduate of currently development
N write a simple completed? attending (NAME) attending? school? technical/ attending training have
E message in school? currently vocational TVET for skills (NAME) attended
any language attending? education and development? including the
N
or dialect? Is it ___? training current one?
U 1 Yes
M (TVET)?
2 No
B 1 Public
E 1 Yes 2 Private (SEE CODES BELOW) If answer in 07
R 1 Yes 2 No, go to 3 Home- (SEE CODES 1 Yes and 08 is No, (SEE CODES
GO TO
2 No (SEE CODES BELOW) 06 schooled GO TO 07 BELOW) 2 No SECTION D
BELOW)

(01) (02) (03) (04) (05) (06) (07) (08) (09)

1
____________ ____________ ___________
SPECIFY SPECIFY SPECIFY ____________
SPECIFY

2
____________ ____________ ___________
SPECIFY SPECIFY SPECIFY ____________
SPECIFY

3
____________ ____________ ___________
SPECIFY SPECIFY SPECIFY ____________
SPECIFY

4
____________ ____________ ___________
SPECIFY SPECIFY SPECIFY ____________
SPECIFY

5
____________ ____________ ___________
SPECIFY SPECIFY SPECIFY ____________
SPECIFY

6
____________ ____________ ___________
SPECIFY SPECIFY SPECIFY ____________
SPECIFY

(02) Highest grade/year completed and (05) Grade/year currently attending (06) Reason for not attending school
Level 0 - Early Childhood Education Sports Track 01 ACCESSIBILITY OF SCHOOL
00000 - No Grade Completed 34031 - Grade 11 02 ILLNESS/DISABILITY
01000 - Nursery 34032 - Grade 12
02000 - Kindergarten 34033 - SHS Graduate 03 PREGNANCY
Level 1 - Primary Education (Elementary) Technology and Livelihood Education and 04 MARRIAGE
10011 - Grade 1 Technical-Vocational Livelihood Track 05 HIGH COST OF EDUCATION/FINANCIAL CONCERN
10012 - Grade 2 35011 - Grade 11 06 EMPLOYMENT
10013 - Grade 3 35012 - Grade 12
10014 - Grade 4 35013 - SHS Graduate (Strand unknown to 07 FINISHED SCHOOLING OR FINISHED POST SECON-
10015 - Grade 5 respondent) DARY OR COLLEGE
10016 - Grade 6 35014 - Home Economics Strand Graduate 08 LOOKING FOR WORK
10017 - Grade 7 (Old Curriculum) 35015 - Information and Communications
09 LACK OF PERSONAL INTEREST
10018 - Graduate Technology Strand Graduate
10003 - Alternative Learning System (ALS) 35016 - Industrial Arts Strand Graduate 10 DUE TO COVID 19 PANDEMIC
10004 - IPEd 35017 - Agri-Fishery Arts Strand Graduate 11 TOO YOUNG TO GO TO SCHOOL
10005 - Madrasah 35018 - TVL Maritime Specialization Strand 12 BULLYING
10006 - SPED Graduate
Level 2 -Lower Secondary (Junior High School) Level 4-Post-Secondary Non-Tertiary Education 13 FAMILY MATTERS
24011 - Grade 7/1st Year 40001 -1st Year 99 OTHERS, SPECIFY: _________
24012 - Grade 8/2nd Year 40002 -2nd Year
24013 - Grade 9/3rd Year 40003 -3rd Year
24014 - Grade 10/4th Year IF Graduate, Specify Program __________ Codes for (9) Skills development training
24015 - JHS Graduate/HS Graduate (old curriculum) Level 5-Short Cycle Tertiary Education
24003 - Alternative Learning System (ALS) 50001 -1st Year A REFRIGERATION AND AIRCONDITIONING
24004 - IPEd 50002 -2nd Year B AUTOMOTIVE/HEAVY EQUIPMENT SERVICING
24005 - Madrasah 50003 -3rd Year
24006 - SPED IF Graduate, Specify Program __________ C METAL WORKER
Level 3 - Upper Secondary (Senior High School) Level 6-Bachelor Level Education or Equivalent D BUILDING WIRING INSTALLATION
Academic Track 60001 - 1st Year E HEAVY EQUIPMENT OPERATION
34011 - Grade 11 60002 - 2nd Year F PLUMBING
34012 - Grade 12 60003 - 3rd Year
34013 - SHS Graduate (Strand unknown to respondent) 60004 - 4th Year G WELDING
34014 - General Academic Strand Graduate 60005 - 5th Year H CARPENTRY
34015 - Accountancy, Business and Management Strand Graduate 60006 - 6th Year I BAKING
34016 - Science, Technology, Engineering and Mathematics Strand IF Graduate, Specify Program __________
J DRESSMAKING
Graduate Level 7-Master Level Education or Equivalent
34017 - Humanities and Social Sciences Strand Graduate 70010 - Undergraduate K LINGUIST
34018 - Pre-Baccalaureate Maritime Specialization Graduate IF Graduate, Specify Program L COMPUTER GRAPHICS
Arts and Design Track Level 8 - Doctoral Level Education or M PAINTING
34021 - Grade 11 Equivalent
34022 - Grade 12 80010 - Undergraduate
N BEAUTY CARE
34023 - SHS Graduate (Strand unknown to respondent) If Graduate, Specify Program__________ O COMMERCIAL COOKING
34024 - Music Strand Graduate P HOUSEKEEPING
34025 - Theater Strand Graduate Q MASSAGE THERAPY
34026 - Visual Arts Strand Graduate
34027 - Media Arts Strand Graduate Z OTHERS, SPECIFY: _______
34028 - Dance Strand Graduate

Version as of 30/08/2021 6 of 40 CBMS Form 2 HPQ

D. COMMUNITY AND POLITICAL PARTICIPATION
This section will ask about you and the members of your household's participation in the activities in your community and/or Barangay.
FOR 15 YEARS OLD AND OVER
Is (NAME) a Did (NAME) vote Did (NAME) Why did (NAME) In the last In the past twelve Did (NAME) In the past twelve (12) months,
registered in the last attend the last not attend the Barangay (12) months, did receive cash or in what volunteer work activities
voter? election? (May Barangay Barangay Assembly that (NAME) volunteer kind as did (NAME) rendered?
2019) Assembly? Assembly? (NAME) attended, in a government or compensation or
L
(First Semester did (NAME) give non-government allowance as a
I
N 2021) suggestions/ program within the volunteer?
E comments/ Philippines?
reactions during
the meeting?
N
U
M
B
E
R Any answer
go to 06
1 Yes
1 Yes 1 Yes 1 Yes, go to 05 1 Yes 2 No, go to 1 Yes
2 No, go to 03 2 No 2 No (SEE CODES 2 No SECTION E 2 No (SEE CODES BELOW)

(01) (02) (03) (04) (05) (06) (07) (08)

1
_____________ ______________________
SPECIFY SPECIFY

2
_____________ ______________________
SPECIFY SPECIFY

3
_____________ ______________________
SPECIFY SPECIFY

_____________ ______________________
SPECIFY SPECIFY

_____________ ______________________
SPECIFY SPECIFY

_____________ ______________________
SPECIFY SPECIFY
(04) Reason for Not Attending Barangay
(08) Area/sector of Volunteer Work
Assembly
1 Didn't know that there is a Barangay Assembly A Volunteering as a teacher in a public school
2 Didn't like to attend/Choose not to attend B Serving in labor or employee’s union
3 No scheduled Barangay Assembly C Serving in neighborhood clean-up committee
9 Others, specify: ________ D Working at a voter's registration drive
E Distributing food, medical, or material assistance to a shelter or during calamities and community pantry
F Serving as a deacon or usher at church
G Helping a nonprofit environmental organization
H Providing free medical assistance
I Providing free legal advice at a legal service agency for indigent prisoners and families
J Making clothes for disadvantaged children
K Constructing housing for homeless families
L Serving as volunteer in the Barangay (e.g. Barangay Tanod, Barangay Health Worker, Lupong Tagapamayapa)
M Tree planting, coastal cleaning and rescuing animals
N Volunteering in Brigada Eskwela
O Volunteering as army reserve
Z Other, specify: _______

CBMS Form 2 HPQ 7 of 40 Version as of 30/08/2021

E. ECONOMIC CHARACTERISTICS
Now we would like to ask information on the job or business activity of each household members in the past week.
FOR PERSONS WHO EVER WORKED OR HAD A JOB/BUSINESS DURING THE PAST WEEK
FOR 5 YEARS OLD AND OVER
Did (NAME) What is Although (NAME) Did (NAME) Where was (NAME)'s location of What was (NAME)'s primary In what kind of industry did
do any work (NAME)'s did not work, did engage in work? occupation during the past (NAME) work during the past
for at least working (NAME) have a job online platform week? week?
L one hour, arrangement? or business during or mobile
I including work the past week? application, for (Specify occupation e.g. (Specify industry e.g. primary/
N from home or at least an elementary school teacher, rice elementary private/public
E telecom- hour, in his/her farmer, etc.) education, growing of paddy
muting, during work/job or rice, etc.)
N the past business in the
U week? past week?
M
B 1 Yes
E 2 No 2 digits for Province
R
3 No, Temporarily 2 digits for City/Municipality

1 Yes ENTER CODE IF ANSWER IS

ENTER ENTER CITY/ Enter Enter
2 No, GO TO THEN CODE 2 or 3, GO 1 Yes
PROVINCE MUNICIPALITY PSOC PSIC
03 GO TO 04 TO 22 2 No
CODE CODE Code Code

(01) (02) (03) (04) (05) (06) (07) (08) (09) (10)

1 _________ _________
SPECIFY SPECIFY

2 _________ _________
SPECIFY SPECIFY

3 _________ _________
SPECIFY SPECIFY

4 _________ _________
SPECIFY SPECIFY

5 _________ _________
SPECIFY SPECIFY

6 _________ _________
SPECIFY SPECIFY

Codes for (02) Working Arrangement

1 Working in the default place of work (not at home)
2 Telecommuting/work from home
3 Home-based work
4 On job rotation
5 On a mixed arrangement
6 On reduced hours

Version as of 30/08/2021 8 of 40 CBMS Form 2 HPQ

E. ECONOMIC CHARACTERISTICS

FOR PERSONS WHO EVER WORKED OR HAD A JOB/BUSINESS DURING THE PAST WEEK

FOR 15 YEARS OLD AND OVER

What is What is What is (NAME)'s Did (NAME) Did (NAME) What is NOTE TO EN: Did What is (NAME)'s What is the main
(NAME)'s (NAME)'s total number of want more look for (NAME)'s If answer in Question (NAME) total number of reason why
nature of normal hours worked during hours of additional class of 16 (Class of Worker) have other hours worked for (NAME) worked
L
employment working hours the past week? work during work during worker? is job or all jobs during the more than 48 or
I
N ? per day the past the past Code 0,1,2,5 business past week? less than 40 hours
E during the week? week? during the during the past
past week? past week?
week?
N
U
M Basic
B Basis of Pay per
E Payment Day
R (In Cash)
IF TOTAL ENTER CODE
(SEE (SEE (SEE HOURS THEN
CODES CODES CODES WORKED IS 40- GO TO
BELOW) BELOW) BELOW) 48 HOURS, SECTION F
1 Yes 1 Yes If answer is 1 Yes GO TO
code 5,6,7
2 No 2 No 2 No SECTION F
go to 19

(11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21)

Codes for (11) Nature of Codes for (16) Class of Codes for (17) Codes for (21) Reasons why worked more than 48 hours
Employment Worker Basis of Payment or less than 40 hours
1 Permanent job/business/ 0 Worked for private household 0 In kind, imputed Worked more than 48 hours Worked less than 40 hours
unpaid family work 1 Worked for private establishment (salaries and wages)
11 Wanted more earnings 20 Variable working time/nature of work
2 Short-term or seasonal or 2 Worked for gov't/gov't corporation 1 Per piece
12 Requirements of the job 21 Holidays
casual job/business, unpaid 2 Per hour
3 Self-employed without any paid 13 Exceptional week 22 Poor business condition
family work
employee, go to 19 3 Per day
3 Worked for different 14 Ambition, passion for job 23 Reduction in clients/work
4 Employer in own family-operated 4 Monthly
employer on day to day or week 15 Due to Covid-19 Pandemic 24 Low or off season
farm or business, go to 19 5 Pakyaw
to week basis Community Quarantine 25 Bad weather, natural disaster
5 Worked with pay in own family- 6 Other salaries/wages,
operated farm or business 99 Others, specify: _______ 26 Strike or labour dispute
specify: _____
6 Worked without pay in own family- 7 Not salaries/wages, 27 Start/end/change of job
operated farm or business, go to 19 specify: _______ 28 Could only find part time work
29 School training
30 Personal/family reasons
31 Health/medical limitations
32 Due to Covid-19 Pandemic
Community Quarantine

CBMS Form 2 HPQ 9 of 40 Version as of 30/08/2021

E. ECONOMIC CHARACTERISTICS

FOR PERSONS WITH NO JOB/BUSINESS DURING THE PAST WEEK

FOR 15 YEARS OLD AND OVER

Did (NAME) look Why did (NAME) If there was Did (NAME) What was the year What was (NAME)'s last In what kind of industry did (NAME)
for work or try to not look for work? opportunity for ever work/ and month when occupation? last work?
establish work in the past had business (NAME) last worked?
L
business during week or within at any time (Specify occupation e.g. (Specify industry e.g. primary/
I
N the past week? two weeks, in the past? elementary school teacher, rice elementary private/public education,
E would (NAME) farmer, etc.) growing of paddy rice, etc.)
been available?

N
U (MM/YYYY)
M
B
E 98 Don't Know for
R MM
9998 Don't Know for
1 Yes, go to 24 SEE CODES 1 Yes 1 Yes YYYY
2 No BELOW 2 No 2 No, go to Enter Enter
SECTION F PSOC PSIC
Code Code

(22) (23) (24) (25) (26) (27) (28) (29) (30)

1
MO YEAR _________ _________
_________ SPECIFY SPECIFY
SPECIFY

2
MO YEAR _________ _________
_________ SPECIFY SPECIFY
SPECIFY

3
MO YEAR _________ _________
_________ SPECIFY SPECIFY
SPECIFY

4
MO YEAR _________ _________
_________ SPECIFY SPECIFY
SPECIFY

5
MO YEAR _________ _________
_________ SPECIFY SPECIFY
SPECIFY

6
MO YEAR _________ _________
_________ SPECIFY SPECIFY
SPECIFY

Codes for (23) Reasons for not looking for work

00 ECQ/Lockdown/Covid 19 Pandemic
01 Tired/believed no work available
02 Awaiting results of previous job application IF ANSWER IS CODES:
03 Temporary illness/disability 00, 01, 02, 03, 04, 05
GO TO 24
04 Bad weather
05 Waiting for rehire/job recall

06 Too young/old
07 Retired
08 Permanent Disability IF ANSWER IS CODES:
06, 07, 08, 09, 10, 99
09 Household, family duties, specify _____ GO TO 25
10 Schooling
99 Others, specify _____

Version as of 30/08/2021 10 of 40 CBMS Form 2 HPQ

F. FAMILY INCOME
The next questions will ask about the sources of income of you and your family members.

a Amount in Philippine Peso (PhP)

b
Less than 40,000 in the past 12 months or Approx less than 3,000 monthly 1
In the past twelve (12) months from October 40,000 – 59,999 in the past 12 months or Approx 3,000 – 4,999 monthly 2
2020 to September 2021, how much was your 60,000 – 99,999 in the past 12 months or Approx 5,000 – 7,999 monthly 3
family’s total income? 100,000 – 129,999 in the past 12 months or Approx 8,000 – 10,999 monthly 4
(01)
130,000 – 259,999 in the past 12 months or Approx 11,000 – 21,999 monthly 5
260,000 – 519,999 in the past 12 months or Approx 22,000 – 42,999 monthly 6
NOTE TO EN: USE COMPUTATION SHEET 520,000 – 919,999 in the past 12 months or Approx 43,000 – 75,999 monthly 7
920,000 – 1,569,999 in the past 12 months or Approx 76,000 – 129,999 monthly 8
1,570,000 – 2,619,999 in the past 12 months or Approx 130,000 – 217,999 monthly 9
2,620,000 and over in the past 12 months or Approx more than 218,000 monthly 10

From Regular and Seasonal Employment

Salaries and wages from regular and seasonal employment A A
Commissions, tips, bonuses, family and clothing allowance, transportation B B
and representation allowance and honoraria
Other forms of compensation C C
From Entrepreneurial Activities
Net receipts derived from the operation of family operated enterprises/ D D
activities
Net receipts derived from the operation of practice of a profession or trade E E
In the past twelve (12) months from October
From Other Sources of Family’s Income
2020 to September 2021, what are the sources
Net share of crops, fruits, and vegetables produced, aquaculture products F F
of your family’s income?
harvested or livestock and poultry raised by other households
(02)
Cash receipts, gifts, support, relief, and other forms of assistance from G G
abroad
1 Yes
Pantawid Pamilyang Pilipino Program (4Ps)Social Pension for Indigent H H
2 No
Senior Citizen I I
Social Amelioration Program (SAP) to Individuals in Crisis Situation J J
Other cash receipts, support, assistance, and relief from domestic sources K K
Dividend from investments L L
Rentals received from non-agricultural lands, buildings, spaces, and other M M
properties
Interests (Interest from bank deposits, interest from loans extended to other N N
families)
Other source of income, specify: _________ Z Z

G. FOOD CONSUMPTION
In the past twelve months (12) months from Food Consumed at Home
October 2020 to September 2021, how much Item Amount In Philippine Peso (PhP)
was your family’s average weekly consumption
a
for the following: Bread and cereals

b Meat (e.g. fresh/chilled/frozen beef, pork, chicken, and other meat; edible
offals; preserved and processed meat)
c Fish and seafood (fresh, chilled or frozen; dried, smoked or salted; canned
or bottled)
d
Milk, cheese and eggs
NOTE TO EN: PLEASE RECORD YOUR
COMPUTATIONS IN A SEPARATE SHEET. e
Oils and fats (e.g. butter, margarine, corn/coconut and other edible oils)
KINDLY SUBMIT THE ACCOMPLISHED
COMPUTATION SHEETS TO YOUR f
Fruits (fresh, dried/preserved) and nuts
SUPERVISOR.
g
Vegetables

h Sugar, jam, honey, chocolate, and confectionery (e.g. ice cream/sorbet/

edible ice, chewing gum, candies, pastilles, meringue, bukayo, etc.)
(01) I Food products not elsewhere classified (e.g. salt, spices and culinary herbs,
sauces, condiments and seasonings, vinegar, broth, soup stock, baby food,
coffeemate)
j
Coffee, tea and cocoa

k
Mineral water, softdrinks, fruit and vegetable juices

Food Regularly Consumed Outside

Item Amount In Philippine Peso (PhP)
l Food regularly bought and eaten by the family members outside the home
like snacks, lunch and others (e.g. food bought and eaten in carinderia/
cafeteria during lunch/snacks in the office)
m Cooked food bought outside the home but eaten at home (e.g. FoodPanda
and Grab Food deliveries or food takeout or delivery for usual merienda/
snacks/ breakfast/lunch/dinner at home)
n Daily allowance for snacks and meals at school of members of the house-
hold who are attending school

Total Family's Average Weekly Food Consumption In Philippine Peso (PhP)

CBMS Form 2 HPQ 11 of 40 Version as of 30/08/2021

H. ENTREPRENEURIAL AND FAMILY SUSTENANCE ACTIVITIES

The next questions will ask about the sources of income of you and your family members.

In the past twelve (12) months, did you or any Yes .................................................................................................................................... 1
(01) member of your family produce goods mainly for
No ..................................................................................................................................... 2 GO TO 03
home consumption?

Fishing, gathering shells, snail, seaweeds, corals, etc. .................................................... A

Logging, gathering forest products like firewood ............................................................... B
What is/are the sustenance activitiy/ies
(02) Hunting and trapping ......................................................................................................... C
conducted by your family?
Farming, gardening ........................................................................................................... D
Raising livestock and poultry ............................................................................................. E

CROP FARMING AND GARDENING such as growing of palay, corn, roots and tu- A A
bers, vegetables, fruits, nuts, orchids, ornamental plants, etc.

LIVESTOCK AND POULTRY RAISING such as raising of carabaos, cattle, hogs, B B

horses, chicken, ducks, etc., and the production of fresh milk, eggs, etc.

FISHING such as capturing fish (with a boat of three tons or less); gathering of fry, C C
shells, seaweeds, etc.; and culturing fish, oysters, mussel, etc.

FORESTRY AND HUNTING such as tree planting (ipil-ipil), firewood gathering, small D D
scale logging (excluding concessionaires), charcoal making, forestry product gather-
ing (cogon, nipa, rattan, bamboo, resin, gum, etc.) or wild animals/birds hunting

MINING AND QUARRYING such as mineral extraction like salt making, gold mining, E E
gravel, sand and stone quarrying, etc.

MANUFACTURING such as mat weaving, tailoring, dressmaking, bagoong making, F F

fish drying, etc.

ELECTRICITY such as using of generators, solar panels, deep well water pump G G

WATER SUPPLY AND WASTE MANAGEMENT such as deep well, hand operated H H
water pump, collection of hazardous and non-hazardous waste
CONSTRUCTION like repair of a house, building, or any structure I I

WHOLESALE AND RETAIL including market vending, sidewalk vending, and ped- J J
In the past twelve (12) months, did you or any dling; REPAIR OF MOTOR VEHICLES AND MOTORCYCLES
member of your family engage as operator in any
TRANSPORTATION AND STORAGE such as jeepney or taxi operations, storage and K K
of the following entrepreneurial activities?
warehousing activities, etc.
(03) 1 Yes POSTAL AND COURIER SERVICES ACTIVITIES such as messengerial services, L L
2 No etc.
ACCOMMODATION AND FOOD SERVICE ACTIVITIES such as hotels, motels, M M
If NO in all industries, GO TO SECTION I resort, condotels, pension houses, camping sites, and restaurants, dormitories, can-
teen, catering, refreshment stands, kiosk, etc.

INFORMATION AND COMMUNICATION such as Youtube vlogging, online content N N

creation, publishing and printing, motion picture/video production, sound recording
and music publishing, etc

FINANCIAL AND INSURANCE ACTIVITIES such as money lending, credit coopera- O O

tives

REAL ESTATE AND OWNERSHIP OF DWELLINGS P P

PROFESSIONAL AND BUSINESS SERVICES such as accounting services, legal Q Q

services, engineering services, architectural services, interior design services, etc.

EDUCATION such as online tutorial, private tutorial, etc R R

HUMAN HEALTH AND SOCIAL WORK ACTIVITIES S S

ADMINISTRATIVE AND SUPPORT SERVICE ACTIVITIES T T

ARTS, ENTERTAINMENT AND RECREATION such as sports activities, theatrical U U

activities, art facilities, activities of amusement parks and theme parks

OTHER SERVICES (spa activities, beauty treatment, beauty parlor and barber shop V V
activities, wellness activities, and other personal activities, repair of computers and
communication equipment’s, Repair of personal and household goods, Funeral Ser-
vices, Laundry Services, Barber Shops, Beauty parlor, Cleaning services, etc.)

Version as of 30/08/2021 12 of 40 CBMS Form 2 HPQ

H. ENTREPRENEURIAL AND FAMILY SUSTENANCE ACTIVITIES

ENTREPRENEURIAL ACTIVITY 1 ENTREPRENEURIAL ACTIVITY 2 ENTREPRENEURIAL ACTIVITY 3

What is/are the major entrepreneurial activity/

(04)
ies of the family? Write Top Three (3)

(05) Enter the PSIC of Entrepreneurial Activity

Does the entrepreneurial activity/ies use e- Yes .................... 1 Yes .................... 1 Yes .................... 1
(06) commerce platform to sell products or deliver
the services? No ..................... 2 No ..................... 2 No ..................... 2

Does the entrepreneurial activity/ies use social Yes .................... 1 Yes .................... 1 Yes .................... 1
(07) media (Facebook, Twitter, Instagram) in selling
goods and/or services? No ..................... 2 No ..................... 2 No ..................... 2

In what year did the family member's

(08)
entrepreneurial activity start to operate?

CODES CODES CODES

October 2020 A October 2020 A October 2020 A

November 2020 B November 2020 B November 2020 B
December 2020 C December 2020 C December 2020 C
January 2021 D January 2021 D January 2021 D
February 2021 E February 2021 E February 2021 E
In the past twelve (12) months, in which March 2021 F March 2021 F March 2021 F
(09) month/s did the family member's
entrepreneurial activity operate? April 2021 G April 2021 G April 2021 G
May 2021 H May 2021 H May 2021 H
June 2021 I June 2021 I June 2021 I
July 2021 J July 2021 J July 2021 J
August 2021 K August 2021 K August 2021 K
September 2021 L September 2021 L September 2021 L
All Months (From Octo- All Months (From Octo- All Months (From Octo-
ber 2020 to September M ber 2020 to September M ber 2020 to September M
2021) 2021) 2021)

On the average, how many persons worked in

or for the family's entrepreneurial activity/ Working owners and Working owners and Working owners and
business every month (with operations) in the unpaid workers unpaid workers unpaid workers
past 12 months?
(10) Paid employees Paid employees Paid employees
NOTE: This includes paid employees, working
owners, unpaid workers and all employees who Total Total Total
work full-time or part-time.

CODES CODES CODES

Barangay LGU A Barangay LGU A Barangay LGU A

City/Municipal LGU B City/Municipal LGU B City/Municipal LGU B
In which of the following government agency/
(11) ies is/are the entrepreneurial activity/ies DTI C DTI C DTI C
registered? BIR D BIR D BIR D
Other government agency E Other government agency E Other government agency E
Not registered F Not registered F Not registered F
Don't know X Don't know X Don't know X
I. FINANCIAL INCLUSION
Now we will ask about the household's financial activities such as opening of bank account, savings, acquiring of loans, etc.

Which of the following formal financial BANK ACCOUNT ....................................................................................... A A

account/s (which is/are active, whether ONLINE BANK ACCOUNT (CIMB, ING) .................................................... B B
personal or joint accounts) do you or any of E-MONEY ACCOUNT (G-CASH) ............................................................... C C
If Yes, GO
(01) your household members have? ACCOUNT WITH NSSLA OR NON STOCK (e.g. AFPSLAI, Manila D TO 03 D
Teachers SLA)
E
1 Yes ACCOUNT WITH COOPERATIVE ........................................................... E F
2 No ACCOUNT WITH MICROFINANCE NGO (e.g. CARD, ASA) .................... F

Don't know the details or how it works ........................................................ A

Don't have the documentary requirements (e.g., ID) to open an account B
Don't trust financial institutions ................................................................... C
What is/are the reason for not having any of the Religious beliefs .......................................................................................... D
financial accounts mentioned in 01? Find the minimum deposit, maintaining balance, and other transaction E
(02) ___________________
fees too expensive SPECIFY
ANSWER THIS IF ANSWER IN 01 (A-F) IS NO Don't need it ................................................................................................ F
Don't have enough money to open an account ........................................... G
GO TO 05
The bank/financial institution is too far away .............................................. H
Others, specify: _________________ ........................................................ Z

CBMS Form 2 HPQ 13 of 40 Version as of 30/08/2021

I. FINANCIAL INCLUSION
To save money ........................................................................................... A
To receive salary, pension or benefits ........................................................ B
To send/receive remittance ......................................................................... C
Why did you or any of your household ___________________
(03) For payments (e.g., loan) ........................................................................... D
members open the financial account/s? SPECIFY
For my business .......................................................................................... E
For online shopping .................................................................................... F
Others, specify: ________ .......................................................................... Z
Saving - For education ................................................................................ A
Saving - For leisure/travel ........................................................................... B
Saving - For emergencies .......................................................................... C
Saving - For opening business/ business expansion ................................. D
Saving - For future events (e.g. birthday, weddings, anniversaries) .......... E
Saving - For investments ............................................................................ F
Saving - For no particular reason or safekeeping ...................................... G
Payment - For Electronic banking (i.e. fund transfer via online banking, H
ATM, mobile app)
How do you or any of your household members Payment - For Automatic debit arrangements ........................................... I
currently use your financial account/s? Payment - For Check Payment .................................................................. J
(04) Payment - For Point-of-sale (POS) using debit cards/cash cards .............. K
Payment - For Bills (e.g. Utilities like Meralco, Manila Water) ................... L
1 Yes
Payment - For Online shopping .................................................................. M
2 No
Payment - For loans ................................................................................... N
For Receiving benefits from a government program (e.g. 4Ps, SAP, Social O
Pension)
For receiving salary .................................................................................... P
For receiving pension ................................................................................. Q
For receiving allowance (student) ............................................................... R
For business operations ............................................................................. S
Others, specify: _____ ................................................................................ Z
___________________
SPECIFY

Do you or any of your household members

Yes .............................................................................................................. 1
(05) save money through any form other than the
No ............................................................................................................... 2 GO TO 07
above identified financial account/s?

At home ...................................................................................................... A
Where do you or any of your household
Ask other people to keep money for me ..................................................... B
members put/keep your savings?
(06) Group savings ............................................................................................ C ___________
Government institutions (GSIS, SSS, Pag-IBIG 2) ..................................... D SPECIFY
ANY ANSWER, GO TO 08
Others, specify _________ ......................................................................... Z

FOR THOSE WHO DOESN'T HAVE CURRENT SAVINGS

(ANSWER IN 01 IS YES AND 04 .A TO 04.G IS NO AND 05 IS NO)
OR
(ANSWER IN 01 IS NO AND 05 IS NO)

Earn just enough/ No extra cash ................................................................ A

Use for celebrations or special occasions .................................................. B
What is/are the reason/s why you or any of
(07) Use for buying gadgets/ appliances/ furniture ............................................ C ___________
your household members don't save money?
Use for activities ......................................................................................... D SPECIFY

Others, specify: _____ ................................................................................ Z

Yes ............................................................................................................. 1
Do you or any of your household members
(08) No ............................................................................................................... 2 GO TO 11
have any loan/s?
Don't know .................................................................................................. 8 GO TO 11
GSIS ........................................................................................................... A
SSS ............................................................................................................. B
Pag-ibig ....................................................................................................... C
Microfinance Institution ............................................................................... D
___________________
Where did you or any of your household Relative/ Friend ........................................................................................... E SPECIFY
(09)
member acquire this/these loan/s? Credit Union ................................................................................................ F
Bank ............................................................................................................ G
Informal lender ............................................................................................ H
Pawnshop ................................................................................................... I
Others, specify: __________ ...................................................................... Z
Business ..................................................................................................... A
Education .................................................................................................... B
Travel/leisure .............................................................................................. C
Medical needs ............................................................................................. D
Daily needs (e.g. Food, rent/housing, electricity, water) ............................. E
(10) What is/are the purpose/s of this/these loan/s? Vehicle ........................................................................................................ F ___________________
Real estate (e.g. house, lot, condo, etc.) .................................................... G SPECIFY
Payment for another loan ............................................................................ H
Appliance .................................................................................................... I
Others, specify _________ ......................................................................... Z

Version as of 30/08/2021 14 of 40 CBMS Form 2 HPQ

I. FINANCIAL INCLUSION
Which of the following insurance products do (12) What is the type of insurance provider? 1 Yes 2 No
you or any of your household members have?
Government Private Insurance
1 Yes 2 No Bank Others, specify:
Insurance Company

Life insurance ............................... A A

Accident insurance ....................... B B
Health insurance ........................... C C
Fire insurance .............................. D D
Vehicle insurance ......................... E E
(11)
Microinsurance ............................. F F
Crop Insurance ............................ G G
Livestock and Poultry Insurance H H
Fisheries Insurance ..................... I I
House insurance .......................... J J
Appliances insurance ................... K K
Others, specify: _________ .......... Z Z

J. HEALTH
In the next questions, we will ask about the health status of the household members. There will be questions about pregnant and lactating women, infant/s and child/ren, persons with
disability, and other sickness experienced by the members of your household. Some of the questions might be sensitive or difficult to answer, but we encourage you to answer as this might
help the government craft programs that might benefit your household and your community.
CHILD BEARING, PREGNANT AND LACTATING MOTHERS

FOR ALL FEMALE HOUSEHOLD MEMBERS

In the past three (3) years, is/are there any female household member/s Yes ....................................................................................... 1
(01)
who had live births? No ....................................................................................... 2 GO TO 05
HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

(02) Who is/are the female household member/s who had live births? LINE NUMBER LINE NUMBER LINE NUMBER

(03) In the past three (3) years, how many were the live births of (NAME)? LIVE BIRTHS .............. LIVE BIRTHS .............. LIVE BIRTHS ...........

In what month and year did (NAME) have her first ever live birth? MONTH ................ MONTH ............... MONTH ...............
(04)
98—Don’t Know (Month) YEAR .... YEAR .... YEAR...

Yes ....................................................................................... 1
(05) Is/are there any female household member/s who are currently pregnant?
No ....................................................................................... 2 GO TO 07
HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

(06) Who is/are the female household member/s who are currently pregnant? LINE NUMBER LINE NUMBER LINE NUMBER

Is/are there any female household member/s who are lactating/ Yes ....................................................................................... 1
(07)
breastfeeding mother? No ....................................................................................... 2 GO TO 09
HH MEMBER 1 HH MEMBER 2 HH MEMBER 3
Who is/are the household member/s who are lactating/breastfeeding
(08) LINE NUMBER LINE NUMBER LINE NUMBER
mother?
CHILD MORTALITY

FOR FORMER HOUSEHOLD MEMBERS 0 TO 5 YEARS OLD

Yes .................................................. 1
(09) In the past three (3) years, was there any child aged zero (0) to five (5) who died?
No .................................................. 2 GO TO 14
CHILD/BABY 1 CHILD/BABY 2 CHILD/BABY 3

(10) What was the name of child or baby?

(Last Name, First Name) (Last Name, First Name) (Last Name, First Name)
Male .................................... 1 Male .................................... 1 Male .................................... 1
(11) What was the sex of the child or baby?
Female .................................2 Female .................................2 Female .................................2

What was the age (in month/s) of the child or

(12) AGE (IN MONTHS ……. AGE (IN MONTHS ……. AGE (IN MONTHS …….
baby when he/she died?

CAUSE OF DEATH ……. CAUSE OF DEATH ……. CAUSE OF DEATH …….

___________________ ___________________ ___________________
SPECIFY SPECIFY SPECIFY
What was the main cause of death of the child or Bacterial sepsis of newborn ………........ 01 Disorders related to short gestation and Intrauterine hypoxia and birth asphyxia
(13)
baby? Pneumonia ………………………...…….. 02 low birth weight, not elsewhere classi- Other congenital malformations …..…. 08
fied 05
Respiratory distress of newborn ………. 03 Diarrhea and gastroenteritis of pre- 09
Congenital pneumonia …………….…. 06
Congenital malformation of the heart … 04 sumed infectious origin 10
Neonatal aspiration syndrome ……....
07 Others specify: __________ ………… 99

CBMS Form 2 HPQ 15 of 40 Version as of 30/08/2021

J. HEALTH
PERSONS WITH DISABILITY

FOR ALL HOUSEHOLD MEMBERS

Yes .................................................. 1
(14) Does any member of this household have a disability?
No .................................................. 2 GO TO 18
HH MEMBER 1 HH MEMBER 2 HH MEMBER 3
Who among the household members have
(15) LINE NUMBER LINE NUMBER LINE NUMBER
disability?

CODE .................... CODE .................... CODE ....................

A VISUAL DISABILITY A VISUAL DISABILITY A VISUAL DISABILITY
B DEAF OR HARD OF HEARING B DEAF OR HARD OF HEARING B DEAF OR HARD OF HEARING
C INTELLECTUAL DISABILITY C INTELLECTUAL DISABILITY C INTELLECTUAL DISABILITY
D LEARNING DISABILITY D LEARNING DISABILITY D LEARNING DISABILITY
(16) What type of disability/ies does (NAME) have? E MENTAL DISABILITY E MENTAL DISABILITY E MENTAL DISABILITY
F PHYSICAL DISABILITY F PHYSICAL DISABILITY F PHYSICAL DISABILITY
(ORTHOPEDIC) (ORTHOPEDIC) (ORTHOPEDIC)
G PSYCHOSOCIAL DISABILITY G PSYCHOSOCIAL DISABILITY G PSYCHOSOCIAL DISABILITY
H SPEECH AND LANGUAGE H SPEECH AND LANGUAGE H SPEECH AND LANGUAGE
IMPAIRMENT IMPAIRMENT IMPAIRMENT
Z OTHERS, SPECIFY ___________ Z OTHERS, SPECIFY ____________ Z OTHERS, SPECIFY ____________
Has (NAME)'s disability/ies been diagnosed by a Yes ....................................... 1 Yes ........................................ 1 Yes ....................................... 1
(17)
doctor? No ....................................... 2 No ........................................ 2 No ....................................... 2
Are there any member of this household who were diagnosed as cancer patients or Yes .................................................. 1
(18)
persons living with cancer? No .................................................. 2 GO TO 20
HH MEMBER 1 HH MEMBER 2 HH MEMBER 3
Who among the household members are cancer
(19) LINE NUMBER LINE NUMBER LINE NUMBER
patients or persons living with cancer?
Yes .................................................. 1
(20) Are there any member of this household who are cancer survivors?
No .................................................. 2 GO TO 22
HH MEMBER 1 HH MEMBER 2 HH MEMBER 3
(21) Who among the household members are cancer
LINE NUMBER LINE NUMBER LINE NUMBER
survivors?
Does any member of this household have rare disease? Yes .................................................. 1
(22)
(Does any member of this household have a seemingly rare disease?) No .................................................. 2 GO TO 28
HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

Who among the household members have rare

disease?
(23) LINE NUMBER LINE NUMBER LINE NUMBER
(Who among the household members has a
seemingly rare disease?)

Has (NAME)'s rare disease been diagnosed by a

Yes ....................................... 1 Yes ........................................ 1 Yes ....................................... 1
(24) doctor?
No ....................................... 2 No ........................................ 2 No ....................................... 2
IF THE ANSWER IS NO, GO TO 26

If answer in 24 is Yes: What is (NAME)'s rare

___________________ ___________________ ___________________
(25) disease? SPECIFY SPECIFY SPECIFY
CODE CODE CODE
ANY ANSWER, GO TO 28
If answer in 24 is No: What is (NAME)'s
(26) __________________________ __________________________ __________________________
seemingly rare disease? SPECIFY SPECIFY SPECIFY

CODE .............................. CODE .............................. CODE ..............................

1 FACILITY /DOCTOR IS FAR 1 FACILITY /DOCTOR IS FAR 1 FACILITY /DOCTOR IS FAR

What is the main reason why (NAME)'s 2 NO MONEY FOR CONSULTATION 2 NO MONEY FOR CONSULTATION 2 NO MONEY FOR CONSULTATION
seemingly rare disease was not diagnosed by a 3 WORRIED ABOUT TREATMENT 3 WORRIED ABOUT TREATMENT 3 WORRIED ABOUT TREATMENT
(27) doctor? COST COST COST
IF ANSWER IN 24 IS NO, ANSWER THIS 4 HOME REMEDY IS AVAILABLE 4 HOME REMEDY IS AVAILABLE 4 HOME REMEDY IS AVAILABLE
QUESTION 5 EXPECT THAT THE DISEASE 5 EXPECT THAT THE DISEASE 5 EXPECT THAT THE DISEASE
WILL IMPROVE WILL IMPROVE WILL IMPROVE
9 OTHERS, SPECIFY: 9 OTHERS, SPECIFY: 9 OTHERS, SPECIFY:
_____________________ _____________________ _____________________
FOR ALL HOUSEHOLD MEMBERS

Yes .................................................. 1
(28) Does any member of this household have Persons With Disability (PWD) ID? GO TO 32
No .................................................. 2
HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

Who among the members of this household has

(29) LINE NUMBER LINE NUMBER LINE NUMBER
a PWD ID?

Yes ....................................... 1 Yes ....................................... 1 Yes ....................................... 1

REQUEST THE RESPONDENT TO SHOW THE
(30) No ....................................... 2 No ....................................... 2 No ....................................... 2
PWD ID
IF NOT SHOWN, GO TO 32 IF NOT SHOWN, GO TO 32 IF NOT SHOWN, GO TO 32

Version as of 30/08/2021 16 of 40 CBMS Form 2 HPQ

J. HEALTH

CODE .................... CODE .................... CODE ....................

01 VISUAL DISABILITY 05 MENTAL DISABILITY 08 SPEECH AND LANGUAGE

RECORD THE TYPE OF DISABILITY SHOWN IN 02 DEAF OR HARD OF HEARING 06 PHYSICAL DISABILITY IMPAIRMENT
(31)
THE PWD ID 03 INTELLECTUAL DISABILITY (ORTHOPEDIC) 09 CANCER (RA11215)
04 LEARNING DISABILITY 07 PSYCHOSOCIAL DISABILITY 10 RARE DISEASE (RA10747)

ILLNESS/SICKNESS/INJURY

In the past twelve (12) months, did you or any of your household members get ill/sick/ Yes ……………………..………….. 1
(32)
injured? No …………...….….…………….. 2 GO TO SECTION K
HH MEMBER 1 HH MEMBER 2 HH MEMBER 3
In the past twelve (12) month, who among the
(33) LINE NUMBER LINE NUMBER LINE NUMBER
members of the household got ill/sick/injured?
In the past twelve (12) months, how many times
(34) NUMBER OF TIMES NUMBER OF TIMES NUMBER OF TIMES
did (NAME) get ill/sick/injured?
In the past month, did any of the illness/sickness/
Yes …………………...... 1 Yes …………………...... 1 Yes …………………...... 1
injury become a reason for not going to work or
(35) school, or not performing daily activities? No …………………...... 2 No …………………...... 2 No …………………...... 2
IF ANSWER IS NO, GO TO 37 IF ANSWER IS NO, GO TO 37 IF ANSWER IS NO, GO TO 37
(If 0-4 years old, skip this question)

In the past month, how many days was (NAME)

not able to go to work or school, or perform daily
(36) activities because of the illness/sickness/injury? NUMBER OF DAYS NUMBER OF DAYS NUMBER OF DAYS

(If 0-4 years old, skip this question)

What was (NAME)'s most recent or current illness/

(37) ___________________ ___________________ ___________________
sickness/injury? SPECIFY SPECIFY SPECIFY
CODE CODE CODE
Yes …………………...... 1 Yes …………………...... 1 Yes …………………...... 1
Did (NAME) avail medical treatment for his/her No …………………...... 2 No …………………...... 2 No …………………...... 2
(38)
most recent or current illness/sickness/injury?
IF ANSWER IS NO, GO TO 41 IF ANSWER IS NO, GO TO 41 IF ANSWER IS NO, GO TO 41

CODE CODE CODE

Where did (NAME) avail medical treatment for his/
(39)
her most recent or current illness/sickness/injury?

What were the sources of payment for the medical CODE CODE CODE
treatment of (NAME)'s in his/her most recent or
(40) current illness/sickness/injury?
__________________________ __________________________ __________________________
OTHERS, SPECIFY OTHERS, SPECIFY OTHERS, SPECIFY
ANY ANSWER, GO TO SECTION K

What was the main reason why (NAME) did not

(41) __________________ __________________ __________________
avail any medical treatment? OTHERS, SPECIFY
CODE OTHERS, SPECIFY
CODE OTHERS, SPECIFY
CODE

(37) ILLNESS/SICKNESS/INJURY (39) MEDICAL TREATMENT FACILITY (40) SOURCE/S OF PAYMENT

COMMON NON-COMMUNICABLE PUBLIC SECTOR ALTERNATIVE MEDICAL A SALARY OR INCOME

DISEASE A REGIONAL HOSPITAL/PUBLIC MEDI- SECTOR B LOAN FROM BANKS AND CREDIT INSTITUTIONS OR MORTGAGE
01 DIABETES CAL CENTER P HILOT/HERBALISTS C SAVINGS
02 CANCER B PROVINCIAL HOSPITAL Q THERAPEUTIC MAS- D DONATIONS, CHARITY ASSISTANCE
C DIRECT HOSPITAL SAGE CENTER
03 HYPERTENSION E PHILHEALTH
D MUNICIPAL HOSPITAL R OTHER ALTERNATIVE
COMMON INFECTIOUS DISEASE F SSS/GSIS/ECC
E RURAL HEALTH UNIT (RHU) /URBAN HEALING
04 TUBERCULOSIS (TB) G HMO/PRIVATE/PRE-NEED INSURANCES
HEALTH CENTER (UHC)/LYING IN
05 ACUTE RESPIRATORY INFECTION H FAMILY, FRIENDS, RELATIVES
F BARANGAY HEALTH STATION NOT MEDICAL SECTOR
06 ACUTE GASTRO-ENTRITIS Z OTHERS, SPECIFY: ___________
G MOBILE CLINIC S SHOP SELLING DRUGS/
07 COMMON COLDS, COUGH/FLU FEVER MARKET
H ISOLATION FACILITY
INJURY
I OTHER PUBLIC HEALTH FACILITY T FAITH HEALER (41) REASON OF NOT AVAILING MEDICAL TREATMENT
08 CUT/WOUND
PRIVATE MEDICAL SECTOR
09 BURN 1 FACILITY IS FAR
J PRIVATE HOSPITAL Z OTHER HEALTH
10 FRACTURE/BROKEN BONE FACILITY NEC 2 NO MONEY
K LYING-IN CLINIC/BIRTHING HOME
11 DISLOCATION/SLIPPED DISK 3 WORRIED ABOUT TREATMENT COST
L PRIVATE CLINIC
12 SURGERY 4 HOME REMEDY IS AVAILABLE
M PRIVATE PHARMACY
13 COVID-19 5 HEALTH FACILITY IS NOT PHILHEALTH ACCREDITED
N MOBILE CLINIC
99 OTHERS, SPECIFY: ________________ 6 EXPECT THAT THE SICKNESS/INJURY WILL IMPROVE
O OTHER PRIVATE HEALTH FACILITY
9 OTHERS, SPECIFY: ____________
O OTHER PRIVATE HEALTH FACILITY

CBMS Form 2 HPQ 17 of 40 Version as of 30/08/2021

K. FOOD SECURITY
Now we would like to ask you and your household's experience in food security in the past twelve (12) months. We will give several statements and you are requested to answer
whether you or others in your household experienced this or not by saying "Yes" or "No".

During the past twelve (12) months, was there a time when you or others in your household...

Worried about not having enough food to eat because of lack of Yes ……………………………….. 1 Don’t Know ………………………. 8
(01)
money or other resources? No ……………………………….. 2
Were unable to eat healthy and nutritious food because of a lack of Yes ……………………………….. 1 Don’t Know ………………………. 8
(02)
money or other resources? No ……………………………….. 2
Ate only a few kinds of foods because of a lack of money or other Yes ……………………………….. 1 Don’t Know ………………………. 8
(03)
resources? No ……………………………….. 2
Had to skip a meal because there was not enough money or other Yes ……………………………….. 1 Don’t Know ………………………. 8
(04)
resources to get food? No ……………………………….. 2
Ate less than you thought you should because of a lack of money or Yes ……………………………….. 1 Don’t Know ………………………. 8
(05)
other resources? No ……………………………….. 2
Yes ……………………………….. 1 Don’t Know ………………………. 8
(06) Ran out of food because of a lack of money or other resources?
No ……………………………….. 2
Were hungry but did not eat because there was not enough money or Yes ……………………………….. 1 Don’t Know ………………………. 8
(07)
other resources for food? No ……………………………….. 2
Went without eating for a whole day because of a lack of money or Yes ……………………………….. 1 Don’t Know ………………………. 8
(08)
other resources? No ……………………………….. 2
L. AGRICULTURAL ACTIVITIES
The next questions will ask about the engagement of the household in agricultural activities. Agricultural activities are activities involving the growing of crops, livestock and
poultry, aquaculture, fishing, etc.

Yes …………………………………………………………….. 1
(01) Does any member of this household own an agricultural land?
No ……………………………………………………………… 2 GO TO 03

FOR ALL HOUSEHOLD MEMBERS

HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

(02) Who among the household members own an agricultural land? LINE NUMBER LINE NUMBER LINE NUMBER

In the past twelve (12) months, was there any member of this
household engaged in any of the following agricultural activities: Yes …………………………………………………………….. 1
(03)
growing of crops, livestock/poultry raising, aquaculture, fishing and/or No ……………………………………………………………… 2 GO TO SECTION M
other agriculture activities such as floriculture and apiculture?

FOR 10 YEARS OLD AND OVER

Who among the household members is/are engaged in any of the

(04) following agricultural activities: growing of crops, livestock/poultry LINE NUMBER LINE NUMBER LINE NUMBER
raising, aquaculture, fishing and/or other agriculture activities?

In what agricultural activity is (NAME) engaged in? 1 Yes 2 No A A A

Growing of Crops ........................................................................... B B
B
Livestock and Poultry raising ......................................................... A C C
C
Aquaculture .................................................................................... B D D
D
Fish capture ................................................................................... C E E
(05) E
Gleaning (gathering of shellfish) .................................................... D F F
F
Renting of agricultural machineries, fishing boats/vessels E
(including the machine/boat operator) F
Z Z Z
Others, specify: __________ .........................................................
______________ ______________ ______________
Z SPECIFY SPECIFY SPECIFY

What is (NAME)'s main agricultural activity?

Growing of Crops ......................................................................... 1

Livestock and Poultry raising ........................................................ 2
Aquaculture .................................................................................. 3
(06) Fish capture ................................................................................... 4
______________________ ______________________ ______________________
Gleaning (gathering of shellfish) …………………………………….. 5 SPECIFY SPECIFY SPECIFY

Renting of agricultural machineries, fishing boats/vessels

(including the machine/boat operator) ………………………………... 6
Others, specify __________ ........................................................ 9
Growing of A Growing of A Growing of A
What is the type of (NAME)'s engagement in the (agricultural Crops
Crops Crops
activity)?
Livestock and B Livestock and B Livestock and B
Operator only ................................................................................. 1 Poultry
Poultry Poultry
Farm owner and operator .............................................................. 2 Aquaculture C Aquaculture C
(07) Aquaculture C
Laborer (Livestock and Poultry, Aquaculture, Fish capture, Other) 3 Fish capture D Fish capture D Fish capture D
Crop farmworker ............................................................................ 4 Gleaning E Gleaning E Gleaning E
Renting F Renting F Renting F
If answer is 1, 2, or 3, GO TO 09
Others, specified Z Others, specified Z Others, specified Z

Version as of 30/08/2021 18 of 40 CBMS Form 2 HPQ

L. AGRICULTURAL ACTIVITIES
For crop farmworker, what kind of work does (NAME) do?
Land Preparation ........................................................................... A
Planting/Transplanting ................................................................... B
(08)
Cultivation ...................................................................................... C
______________________ ______________________ ______________________
Harvesting ...................................................................................... D OTHERS, SPECIFY OTHERS, SPECIFY OTHERS, SPECIFY

Others, specify: ________ ............................................................. Z

Is (NAME) a member of any agricultural organization? Yes …………… 1 Yes …………… 1 Yes …………… 1
(09)
If the answer is No, GO TO 11 No …………… 2 No …………… 2 No …………… 2

ORG 1 _____________ ORG 1 _____________ ORG 1 _____________

What is/are the name/s of the organization/s that (NAME) is a member
(10) ORG 2 _____________ ORG 2 _____________ ORG 2 _____________
of?
ORG 3 _____________ ORG 3 _____________ ORG 3 _____________

FOR GROWING OF CROPS OPERATOR

HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

ENTER LINE NUMBER OF HOUSEHOLD MEMBER/S WHO IS/ARE

LINE NUMBER LINE NUMBER LINE NUMBER
GROWING OF CROPS OPERATOR

In the past twelve (12) months, what were the permanent and Palay A Palay A Palay A
temporary crops planted by (NAME)? Corn B Corn B Corn B
Yes ................................................................................................. 1 Banana C Banana C Banana C
No ................................................................................................... 2 Coconut D Coconut D Coconut D
Mango E Mango E Mango E
Sugarcane F Sugarcane F Sugarcane F
(11) Pineapple G Pineapple G Pineapple G
Cassava H Cassava H Cassava H
Rubber I Rubber I Rubber I
Sweet Potato J Sweet Potato J Sweet Potato J
Tobacco K Tobacco K Tobacco K
Other Crops; Z Other Crops; Z Other Crops; Z
specify: _______

Which among the following draft animals/agricultural equipment/ (13) How many of the following agricultural equipment/facilities are owned, rented, and used
facilities does the household members use in crop farming? rent-free by the household member for crop farming?

1 Yes 2 No OWNED RENTED RENT-FREE TOTAL

Carabao ......................................................................... A Carabao ...................................................... A

Cattle ............................................................................. B Cattle ........................................................... B
Horse .............................................................................. C Horse ........................................................... C
Plow ................................................................................ D Plow ............................................................. D
Mechanical Weeder ........................................................ E Mechanical Weeder ..................................... E
Sprayer and duster ......................................................... F Sprayer and duster ...................................... F
(12) Sprinkler ......................................................................... G Sprinkler ....................................................... G
Rotary tillers / Rotavator ................................................. H Rotary tillers / Rotavator .............................. H
Hand tractor (power tiller) ............................................... I Hand tractor (power tiller) ............................ I
Mower ............................................................................. J Mower .......................................................... J
Thresher ......................................................................... K Thresher ...................................................... K
Harvester ........................................................................ L Harvester ..................................................... L
Mechanical dryer ............................................................ M Mechanical dryer .......................................... M
Irrigation pump ................................................................ N Irrigation pump ............................................. N
Others, specify: ____________ ...................................... Z Others, specify: ____________ ................... Z

In the last three (3) years, was your household continuously engaged in Yes ........................................................................................ 1
(14) crop farming activity in your current Barangay of residence?
No ......................................................................................... 2 GO TO 18

Compared with three (3) years ago, did your household's latest Decrease ............................................................................... 1 GO TO 16
(15) harvest ___? Increase ................................................................................ 2 GO TO 18
Remain the same .................................................................. 3 GO TO 18
What is the primary reason for the decrease in total harvest? Affected by drought ............................................................... 01
Affected by typhoon .............................................................. 02
If the answer is 7, 8 and 9, 99, GO TO 18 Affected by flood .................................................................. 03
Affected by pests .................................................................. 04 _____________________
SPECIFY
Decrease in the supply of water from irrigation system ........ 05
(16) Plant/crop diseases ............................................................... 06
Increase in the cost of farm inputs such as seeds, fertilizer, 07
pesticides, etc.
Decrease in land area ........................................................... 08
Changed in the primary occupation of member .................... 09
Others, specify: _______ ...................................................... 99

CBMS Form 2 HPQ 19 of 40 Version as of 30/08/2021

L. AGRICULTURAL ACTIVITIES

What is the percentage decrease of the latest harvest due to (reason

(17) for decrease in harvest) compared to your household's usual harvest PERCENT
three years ago?

FOR LIVESTOCK AND POULTRY OPERATOR

HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

ENTER LINE NUMBER OF HOUSEHOLD MEMBER/S WHO IS/ARE

LINE NUMBER LINE NUMBER LINE NUMBER
LIVESTOCK AND POULTRY OPERATOR

Carabao A Carabao A Carabao A

Cattle B Cattle B Cattle B
In the past twelve (12) months, what were the kinds of livestock Goat C Goat C Goat C
and poultry raised and tended by (NAME)?
Swine D Swine D Swine D
(18)
Yes ................................................................................................... 1 Chicken E Chicken E Chicken E
No .................................................................................................... 2 Duck F Duck F Duck F
Others, specify Z Others, specify Z Others, specify Z
_______ _______ _______

What are the machineries, equipment, and facilities and other (20) How many of the following machineries, equipment, and facilities and other tools being
tools being used in raising/tending livestock/poultry? used in raising/tending livestock/poultry?

1 Yes 2 No
OWNED RENTED RENT-FREE TOTAL

Milking machine .............................................................. A Milking machine ............................................. A

Egg classifying machine ................................................. B Egg classifying machine ................................ B

Tricycle/Motorcycle ......................................................... C Tricycle/Motorcycle ........................................ C

Truck and other vehicle (Delivery, Conveyor, Pog-pog, D Truck and other vehicle (Delivery, Conveyor, D
(19) etc.) Pog-pog, etc.)

Ear Tagger ..................................................................... E Ear Tagger ..................................................... E

Sprayer and Duster ........................................................ F Sprayer and Duster ....................................... F
Syringe/Vaccinator ......................................................... G Syringe/Vaccinator ........................................ G
Weighing scale ............................................................... H Weighing scale .............................................. H
Others, specify _________ ............................................ Z Others, specify _________ ............................ Z

In the last three (3) years, was your household continuously Yes ....................................................................................... 1
(21) engage in livestock and poultry raising activity in your current
Barangay of residence? No ......................................................................................... 2 GO TO 25

Decrease .............................................................................. 1 GO TO 23
Compared with three (3) years ago, did the volume/number of
(22) Increase ................................................................................ 2 GO TO 25
household's livestock and poultry raise/produce ____?
Remain the same .................................................................. 3 GO TO 25

Stricken with diseases .......................................................... 1

(swine flu, bird flu, foot and mouth disease)
Affected by typhoon .............................................................. 2
What is the primary reason for the decrease in volume/number of
Affected by flood ................................................................... 3
(23) livestock and poultry raised/produced?
Affected by extreme hot weather condition ........................... 4
If the answer is 5 and 6, 9, GO TO 25
Increase in cost of inputs (feeds, chicks, etc.) ...................... 5
Decrease in land holding ...................................................... 6
______________________
Others, specify _______ ....................................................... 9 SPECIFY

What is the percentage decrease of the latest livestock/poultry

produced due to (reason for decrease in volume/number)
(24) PERCENT
compared to your household's usual volume of production three
years ago?

Version as of 30/08/2021 20 of 40 CBMS Form 2 HPQ

L. AGRICULTURAL ACTIVITIES
FOR GROWING OF CROPS and/or LIVESTOCK AND POULTRY OPERATOR

HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

ENTER LINE NUMBERS OF GROWING OF CROPS AND

LINE NUMBER LINE NUMBER LINE NUMBER
LIVESTOCK AND POULTRY OPERATOR

How many parcels are being operated/managed by (NAME) (either

(25) NO. OF PARCELS NO. OF PARCELS NO. OF PARCELS
alone or jointly with someone else)?

Parcel 1 Parcel 2 Parcel 3 Parcel 1 Parcel 2 Parcel 3 Parcel 1 Parcel 2 Parcel 3

Where was the parcel located?
(26) Within the Barangay ................................................................ 1
Outside the Barangay .............................................................. 2

Is the (PARCEL) co-operated or co-managed with another

person?
(27) Yes, specify the name/s: ............................................................ 1
No ............................................................................................. 2 _______ _______ _______ _______ _______ _______ _______ _______ _______
Specify Specify Specify Specify Specify Specify Specify Specify Specify
Don’t Know ............................................................................... 8 Name/s Name/s Name/s Name/s Name/s Name/s Name/s Name/s Name/s

Is there a formal document or certificate for this (PARCEL) issued

by the Land Registration Authority or other government agency
that issues proof of land ownership?
(28) Yes ........................................................................................... 1
No ............................................................................................ 2
Don’t Know ............................................................................... 8
What is the tenure status of the parcel that (NAME) operates/
manages?
Fully owned .............................................................................. 01
Owner-like possession (not CBFMA/Stewardship or ownership 02
document unknown to respondent)
Leased/Tenanted ..................................................................... 03
Rented ..................................................................................... 04
Rent-free ................................................................................... 05
(29) Owned under Certificate of Land Transfer (CLT) or Certificate 06
of Land Ownership Award (CLOA)
______ ______ ______ ______ ______ ______ ______ ______ ______
Held under Certificate of Ancestral Domain Title/Certificate of 07 SPECIFY SPECIFY SPECIFY SPECIFY SPECIFY SPECIFY SPECIFY SPECIFY SPECIFY
Ancestral Land Title (CADT/CALT)
Held under Community-Based Forest Management Agreement 08
(CBFMA)/Stewardship)
Don't Know ............................................................................... 96
Others, specify __________ ................................................... 98

Is (NAME) listed as owner or use rights holder on the formal

document for the (PARCEL)?
(30) Yes .............................................................................................. 1
No ................................................................................................ 2
Don’t Know .................................................................................. 8

Does (NAME) have the right to sell the (PARCEL), either alone or
jointly with someone else?
(31) Yes .............................................................................................. 1
No ................................................................................................ 2
Don’t Know .................................................................................. 8

Does (NAME) have the right to bequeath the (PARCEL), either

alone or jointly with someone else?
(32) Yes .............................................................................................. 1
No ................................................................................................ 2
Don’t Know .................................................................................. 8

Was the parcel irrigated as of October 1, 2021?

Yes .............................................................................................. 1
(33)
No ................................................................................................ 2
If answer is No, GO TO 35

What is the status of irrigation of the parcel? (Go to 36)

(34) Fully integrated ............................................................................ 1
Partially irrigated …………………………………………………….. 2

Is the farm (parcel) operated by (NAME) rainfed upland/rainfed

lowland?
(35)
Rainfed upland ……………………………………………………….. 1
Rainfed lowland ………………………………………………………. 2

______.__ ______.__ ______.__ ______.__ ______.__ ______.__ ______.__ ______.__ ______.__

(36) What is the physical area of the parcel?
in hectares in hectares in hectares in hectares in hectares in hectares in hectares in hectares in hectares

What is the total physical area of all the parcels of land operated by the
(37)
household members? IN HECTARES

CBMS Form 2 HPQ 21 of 40 Version as of 30/08/2021

L. AGRICULTURAL ACTIVITIES

FOR AQUACULTURE OPERATOR

HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

ENTER LINE NUMBERS OF OPERATORS IN AQUACULTURE LINE NUMBER LINE NUMBER LINE NUMBER

(38) How many aquafarms are being operated by (NAME)? NO. OF FARM/S NO. OF FARM/S NO. OF FARM/S

Aquafarm Aquafarm Aquafarm Aquafarm Aquafarm Aquafarm Aquafarm Aquafarm Aquafarm

1 2 3 1 2 3 1 2 3
Where is the location of the aquafarm?
(39) Within the Barangay ............................................................... 1
Outside the Barangay .............................................................. 2

What is the type of the aquafarm being operated by (NAME)?

If answer is 8 or 9, proceed to 42
Fishpond ................................................................................... 1

Fish Tank .................................................................................. 2

Fish Pen .................................................................................... 3 _______ _______ _______ _______ _______ _______ _______ _______ _______
Specify Specify Specify Specify Specify Specify Specify Specify Specify
Fish Cages ................................................................................ 4
(40)
Seaweed Farm ......................................................................... 5

Mussel Farm ............................................................................. 6

Oyster (Talaba) Farm ................................................................ 7

Don’t Know …………………....................................................... 8
Others, specify __________ ..................................................... 9

Area Area Area Area Area Area Area Area Area

(in sq. m.) (in sq. m.) (in sq. m.) (in sq. m.) (in sq. m.) (in sq. m.) (in sq. m.) (in sq. m.) (in sq. m.)

What is the measurement of the aquafarm?

(41)
If answer in 40 is 1,3,4,5,6,7 ask AREA
Volume Volume Volume Volume Volume Volume Volume Volume Volume
If answer in 40 is 2, ask VOLUME (in cubic m) (in cubic m) (in cubic m) (in cubic m) (in cubic m) (in cubic m) (in cubic m) (in cubic m) (in cubic m)

What is the type of water environment used in the aquafarm?

Freshwater ................................................................................ 1
(42)
Brackish water .......................................................................... 2
Marine water ............................................................................. 3

What is the tenurial status of the aquafarm?

Owned with Transfer Certificate Title ........................................ 01
Owned with Tax Declaration...................................................... 02
Government owned with Fishpond Lease Agreement (FLA) 03
Government owned without Fishpond Lease Agreement (FLA) 04
Government owned with Gratuitous Permit ............................... 05 _______ _______ _______ _______ _______ _______ _______ _______ _______
(43) Specify Specify Specify Specify Specify Specify Specify Specify Specify
Government owned with City/Municipal License ....................... 06
Lessee ....................................................................................... 07
Sub-lessee ................................................................................. 08
Sub-sub Lessee ........................................................................ 09
Rent-free ................................................................................... 10
Others, specify: _______________........................................... 99

Version as of 30/08/2021 22 of 40 CBMS Form 2 HPQ

L. AGRICULTURAL ACTIVITIES

What are the machineries, equipment, and facilities being (45) How many of the following machineries, equipment, and facilities are being
(44) used in your aquafarm? used in your aquafarms?

1 Yes 2 No

OWNED RENTED RENT-FREE TOTAL

Nets ................................................................................. A Nets ............................................................... A

Boat/Raft ......................................................................... B Boat/Raft ....................................................... B
Weighing scale ................................................................ C Weighing scale .............................................. C
Paddle Wheels ................................................................ D Paddle Wheels .............................................. D
Aerators/Blower ............................................................... E Aerators/Blower ............................................ E
Oxygen Tank.................................................................... F Oxygen Tank.................................................. F
Fish Grader ..................................................................... G Fish Grader ................................................... G
Fish Container ................................................................. H Fish Container ............................................... H
Hatching Cones ............................................................... I Hatching Cones ............................................ I
Incubator ......................................................................... J Incubator ....................................................... J
Refractometer and other Water Quality Monitoring K Refractometer and other Water Quality K
Monitoring Equipment ...................................
Water Pumps................................................................... L Water Pumps................................................. L
Freezer ........................................................................... M Freezer .......................................................... M
Feed Grinder ................................................................... N Feed Grinder ................................................. N
Feed Dispenser ............................................................... O Feed Dispenser ............................................. O
Electric Generator ........................................................... P Electric Generator ......................................... P
Fish Transporter .............................................................. Q Fish Transporter ............................................ Q
Tanks (Fiberglass, wooden, concrete) ............................ R Tanks (Fiberglass, wooden, concrete) .......... R
Aquarium ......................................................................... S Aquarium ....................................................... S
Worker's Hut/Guard Shed ............................................... T Worker's Hut/Guard Shed ............................. T
Storage/Warehouse Building .......................................... U Storage/Warehouse Building ........................ U
Farm Office/Staff House ................................................. V Farm Office/Staff House ............................... V
Farm Laboratory ............................................................. W Farm Laboratory ........................................... W
Water Reservoir .............................................................. X Water Reservoir ............................................ X
Others, specify: __________ .......................................... Z Others, specify: __________ ........................ Z

In the last three (3) years, was your household continuously Yes ........................................................................................ 1
(46) engaged in aquaculture activity in your current Barangay of
No ......................................................................................... 2 GO TO 50
residence?

Decrease ............................................................................... 1 GO TO 48
Compared with three (3) years ago, did your household's latest
(47) Increase ................................................................................ 2 GO TO 50
production ___?
Remain the same.................................................................. 3 GO TO 50

Affected by natural calamities (typhoons, floods,

soil erosions, excessive heat, etc.) ................................ 1
What is the primary reason for the decrease in production from the Sudden change of weather conditions ................................. 2
aquafarm/s? Pollution/Contamination ........................................................ 3
(48)
Pests and diseases ............................................................... 4
______________________
If the answer is 5 and 6, 9 skip to 50 High cost of material inputs ................................................... 5 SPECIFY

Competition brought by imported species …......................... 6

Other, specify: __________ .................................................. 9

What is the percentage decrease of the latest production due to

(49) (reason for decrease in harvest) compared to your household's PERCENT
usual harvest three years ago?

CBMS Form 2 HPQ 23 of 40 Version as of 30/08/2021

L. AGRICULTURAL ACTIVITIES
FOR FISH CAPTURE OPERATOR

Yes ........................................................................................ 1
(50) Does any member of the household use boat/vessel for fishing? GO TO 55
No ........................................................................................ 2

HH MEMBER 1 HH MEMBER 2 HH MEMBER 3

ENTER LINE NUMBER OF OPERATORS IN FISH CAPTURE LINE NUMBER LINE NUMBER LINE NUMBER

(51) How many boats/vessels does the household use for fishing? NO. OF UNITS NO. OF UNITS NO. OF UNITS

Boat/ Boat/ Boat/ Boat/ Boat/ Boat/ Boat/ Boat/ Boat/

Where is the fishing operation usually performed?
Vessel 1 Vessel 2 Vessel 3 Vessel 1 Vessel 2 Vessel 3 Vessel 1 Vessel 2 Vessel 3
Inland Municipal 1
(52)
Marine Municipal 2
Marine Commercial 3

What is the type of the fishing boat/vessel used for fishing?

Boat with engine and outrigger 1
Boat with engine but without outrigger 2
(53)
Boat without engine but with outrigger 3
Boat without engine and outrigger 4

Is the boat/vessel used in fishing owned, or not owned/rent?

Owned 1
(54)
Not Owned/Rented 2

What types of fishing gears/accessories are being used in the (56) How many of the following Fishing gears/accessories are being used in your fishing
fishing operation? operation?
OWNED RENTED RENT-FREE TOTAL

Handline (hook/bait and line) .......................................... A Handline (hook/bait and line) ......................... A
Gill net ............................................................................ B Gill net ........................................................... B
Traps/Pots ...................................................................... C Traps/Pots ..................................................... C
Bottom set longline ......................................................... D Bottom set longline ........................................ D
Lift net ............................................................................. E Lift net ............................................................ E
Scoop net ....................................................................... F Scoop net ...................................................... F
Spear Gun ...................................................................... G Spear Gun ..................................................... G
(55) Push net ......................................................................... H Push net ........................................................ H
Cast net .......................................................................... I Cast net ......................................................... I
Troll line .......................................................................... J Troll line ......................................................... J
Squid Jig ......................................................................... K Squid Jig ........................................................ K
Beach Seine ................................................................... L Beach Seine .................................................. L
Ring net .......................................................................... M Ring net ......................................................... M
Bag net .......................................................................... N Bag net ......................................................... N
Purse Seine .................................................................... O Purse Seine ................................................... O
Trawl ............................................................................... P Trawl .............................................................. P
Others, specify __________ ........................................... Z Others, specify __________ .......................... Z

In the last three (3) years, was your household continuously Yes ........................................................................................ 1
(57) engaged in fishing in the municipal and/or commercial/marine
waters while staying/living continuously in this barangay? No ......................................................................................... 2 GO TO SECTION M

Decrease ............................................................................... 1 Go to 59
Compared with three (3) years ago, did your household's fish
(58) Increase ................................................................................ 2 GO TO SECTION M
catch ___?
Remain the same .................................................................. 3 GO TO SECTION M

What is the primary reason for the decrease in fish catch? Occurrence of coral bleaching .............................................. 01
Occurrence of fish kill ........................................................... 02
Occurrence of oil spill and other kinds of pollution ............... 03
Frequent occurrence of typhoons ......................................... 04
Decrease in fishing area due to government restrictions 05
Decrease in fishing area due to competition ......................... 06 ______
(59) Decrease in fishes/fish stock ................................................ 07 SPECIFY

Less frequent fishing because of the increase in .................. 08 GO TO SECTION M

fuel prices and other expenses
Shift to other forms of livelihood/employment/business 09 GO TO SECTION M
Major damage to banca/vessel ............................................. 10 GO TO SECTION M
Others, specify: _______ ...................................................... 99 GO TO SECTION M

What is the percentage decrease of the latest fish catch due to

(60) (reason for decrease in fish catch) compared to your usual volume PERCENT
of fish caught three years ago?

Version as of 30/08/2021 24 of 40 CBMS Form 2 HPQ

M. CLIMATE CHANGE AND DISASTER RISK MANAGEMENT
Now we would like to ask whether your household experience disaster as well as preparedness.

Did your household reside continuously in this barangay since three Yes ...................................................................................... 1
(01)
(3) years ago? No ........................................................................................ 2 GO TO 07

Decrease in water supply ..................................................... A If Yes, answer also 03 A

Compared with three (3) years ago, did the household experience
More frequent flooding ......................................................... B If Yes, answer also 04 and 05 B
the following in their barangay?
(02) More frequent drought ......................................................... C If Yes, answer also 06 C
Yes .................................................................................................. 1 If Yes, answer also 07
Hotter temperature ............................................................... D D
No ................................................................................................... 2 If Yes, answer also 07
More frequent brownouts ..................................................... E E

ASK QUESTION 03, IF YES IN QUESTION 02 - A Decrease in water supply

Drought ................................................................................ 1
Broken faucet/pump ............................................................. 2
What is the primary reason for the decrease in water supply? Lower water level in the dam ............................................... 3
(03)
GO TO 07 Less frequent delivery of tanker truck/peddler ..................... 4
Increase in number of consumers ........................................ 5
Others, specify: _____________ ........................................ 9

ASK QUESTIONS 04 AND 05, IF YES IN QUESTION 02 - B More frequent flooding

Three (3) years ago, how long does it usually take for the flood to
(04) NUMBER OF HOURS ...............................................................................
subside?

In the past twelve (12) months, how long does it usually take for the
(05) NUMBER OF HOURS ...............................................................................
flood to subside?

ASK QUESTION 06, IF YES IN QUESTION 02 - C More frequent drought

(06) In the past three (3) years, how long does the last drought occur? NUMBER OF MONTHS ............................................................................

ASK QUESTION 07, IF YES IN QUESTION 02 - D Hotter temperature and E More frequent brownouts

Yes ...................................................................................... 1
(07) Do you know the location of your evacuation area?
No ........................................................................................ 2

In the past three (3) years, did the household members temporarily
Yes ...................................................................................... 1
evacuate from this house/place of residence at least once due to
(08) No ........................................................................................ 2 GO TO 13
natural calamities, man-made disaster/event, peace and order or
Don’t know ........................................................................... 8 GO TO 13
relocation?

Typhoon ................................................................................ 01
Flood ..................................................................................... 02
Drought ................................................................................. 03
Earthquake ........................................................................... 04 _________
In the past three (3) years, what is the household's main reason for Volcanic eruption .................................................................. 05 SPECIFY
(09)
moving out/evacuating temporarily from its house/place of residence? Landslide/mudslide ............................................................... 06
Fire ........................................................................................ 07
Epidemic/Pandemic .............................................................. 08
Armed conflict ....................................................................... 09
Others, specify: ___________ .............................................. 99

Did your household's last temporary evacuation occur in the past 12 Yes ...................................................................................... 1
(10)
months? No ........................................................................................ 2 GO TO 13

School ................................................................................... 1
Church .................................................................................. 2
Covered court/gym ............................................................... 3
Where did you stay during your household's last temporary Relative’s house ................................................................... 4
(11)
evacuation? Neighbor’s or friend’s house ................................................. 5
Barangay hall ........................................................................ 6
Dedicated evacuation center ................................................ 7
Others, specify: __________ ................................................ 9 _________
SPECIFY

(12) How long did your household stay in the evacuation area? (in days) NUMBER OF DAYS ...............................................................................

CBMS Form 2 HPQ 25 of 40 Version as of 30/08/2021

 M. CLIMATE CHANGE AND DISASTER RISK MANAGEMENT
ASK QUESTION 17, IF THE ANSWER IN ANY TYPE OF ASSISTANCE LISTED IN
ASK QUESTION 14 TO 16. IF THE ANSWER IN ANY OF THE CALAMITIES LISTED IN 13 is "YES”
16 is "YES"
In the past twelve (12) months, which of the What are the impacts of (CALAMITY) to you/your household What is the estimated total cost of Did you or any of your household members receive any of Which entity/ies provided the assistance to the household during the disaster/s that
following calamities negatively affected your member/s? damages to your property because of the following assistance? your household encountered in the past twelve (12) months?
household? these calamities?
(in Philippine Pesos)

Version as of 30/08/2021
NOTE: If all calamities experienced by 1 Yes 1 Yes
1 Yes the household caused no damage to
1 Yes 2 No 2 No
property of the household, GO TO 16
2 No
2 No

(13) (14) (15) (16) (17)

26 of 40
Relief goods
Financial aid
Livelihood
Trainings
Others, specify
NGA (including RLA), GOCC
LGU
Religious group
Business
CSO
International organization
Relative
Private individual (non-relative)
Others, specify

Death
Injuries
Damage to property
Suspension of classes
Disruption in daily economic activity
Others, specify
A Typhoon A A A
B Flood B B B
C Drought C C C
D Earthquake D D D
E Volcanic Eruption E E E
F Landslide/mudslide F F F
G Fire G G G
H Pandemic/epidemic H H H
I Armed conflict I I I
Z Others, specify Z Z Z

CBMS Form 2 HPQ

M. CLIMATE CHANGE AND DISASTER RISK MANAGEMENT
Yes ...................................................................................... 1 GO TO 18.1
(18) Do you have a disaster preparedness kit?
No ........................................................................................ 2 GO TO 24

Yes ...................................................................................... 1
(18.1) Can you please show your disaster preparedness kit to me?
No ........................................................................................ 2 GO TO 24
How many ___ are there in the How much is the total cost of Considering the number of
Does your preparedness kit contain the following? kit? ___? household members and
1- Yes 2 - No, go to next item possible users of ____, how
many days will the ___ last?
(20) (21) (22)

FOOD A PhP
MAINTENANCE MEDICINE B PhP
CLOTHES C PhP
INFANT NEEDS D PhP
MEDICAL KIT E PhP
MONEY (cash) F PhP
IMPORTANT DOCUMENTS G
(19)
WATER (liter) H PhP
MATCHES/LIGHTER (piece) I PhP
CANDLE (piece) J PhP
BATTERY (piece) K PhP
FACE MASKS (piece) L PhP
FLASHLIGHT (piece) M PhP
RADIO (piece) N PhP
WHISTLE (piece) O PhP
BLANKET (piece) P PhP
CELLPHONE (piece) Q PhP
OTHERS, SPECIFY: _______ Z PhP
NOTE TO EN: Check and mention the unit of measure
TOTAL COST OF THE DISASTER PREPAREDNESS KIT
(23) SUM OF ALL ANSWERS IN 21 PhP
CONTENTS
In the past twelve (12) months, did you or any of your household Yes ...................................................................................... 1
(24) members participate in crafting the Disaster Risk Reduction No ........................................................................................ 2 GO TO 26
Management (DRRM) plan in the Barangay?
Member of the Brgy Disaster Mgmt Committee or Brgy A A
In what ways did you or any of your household members participate in
Council/Kagawad/Chairperson
crafting the Disaster Risk Reduction Management (DRRM) plan in the
Member of the Brgy Emergency Response Team or Brgy B B
Barangay?
volunteer/worker/employee
(25)
Participated in barangay assembly where the Brgy DRRM C C
plan was discussed
1 Yes
Provided written comments to the Brgy DRRM plan D D
2 No
Others, specify__________ Z Z
In the past 12 months, did you or any members of your household
Yes ...................................................................................... 1
(26) receive information from the barangay about natural disasters
No ........................................................................................ 2
preparedness either thru meetings or written notice/information?
In the past twelve (12) months, did you discuss with your household Yes ...................................................................................... 1
(27)
how to prepare for disasters? No ........................................................................................ 2
Do you know any contact number or hotlines which you can contact in Yes ...................................................................................... 1
(28)
case of emergency? No ........................................................................................ 2
Does your household have a written or printed evacuation plans in Yes ...................................................................................... 1
(29)
case of earthquake, flood, landslide, tsunami, storm surge, or fire? No ........................................................................................ 2
N. E-COMMERCE AND DIGITAL ECONOMY
In the next questions, we will ask about your household's internet connectivity and where are you using this technology.

In the past 12 months, do you or any member of your household have Yes ............................................................................. 1
(01)
access to internet? No ............................................................................... 2 GO TO SECTION O

Home .......................................................................... A
A
School/work place ...................................................... B
B
Relatives/friends/neighbors’ home ............................. C
Where does your household access the internet? C
Barangay/community facility ....................................... D
(02) D
1 Yes Computer shop ............................................................ E
E
2 No Others, specify ............................................................. Z
Z

_____________
SPECIFY

CBMS Form 2 HPQ 27 of 40 Version as of 30/08/2021

N. E-COMMERCE AND DIGITAL ECONOMY

Does this household have its own internet at home which can be used Yes ............................................................................. 1
(03)
by any household member when needed? No ............................................................................... 2 GO TO 05

Fixed (wired) narrowband/broadband network [e.g. via

Digital Subscriber Line (DSL), cable modem, high
speed leased line, fiber-to-the-home/building, A A
powerline, and other fixed (wired) broadband]

What types of internet connection are available at home? Fixed (wireless) broadband network [e.g. via WiMAX B
B
and fixed Code Division Multiple Access (CDMA)]
(04)
1 Yes C
Satellite broadband network C
2 No
Mobile broadband network [e.g. via handset, card (e.g.
integrated Subscriber Identity Module or SIM card) or D D
USB modem]

Do you or any member of your household member pay (whether Yes ............................................................................. 1
(05)
prepaid or postpaid) when you access the internet? No ............................................................................... 2

In the past twelve (12) months, for which of the following activities did Access to Information .................................................. A A GO TO 08
you or any of your household member use the Internet for private
Communication, civic participation and collaboration B B GO TO 08
purposes?
Electronic commerce, trade and transactions ............. C C IF YES, GO TO 07
1 Yes
(06) Learning ....................................................................... D D GO TO 08
2 No
Professional life ............................................................ E E GO TO 08

Entertainment, digital content consumption ................. F F GO TO 08

Digital content creation ................................................. G G GO TO 08

Internet retail (Shopee, Lazada) .................................. A

A
Online travel (Klook, Cebu Pacific, Philippine Airlines) B
B
What were the e-commerce platforms/applications/websites that the C
Online media (Facebook, Twitter) ................................ C
household member/s use in the past twelve (12) months?
Online delivery (Foodpanda, Ninjavan, Lalamove, D
(07) Ask if answer in 6.C is Yes toktok, etc.) .................................................................. D
Ride hailing (Grab, Angkas) ........................................ E E
1 Yes
Digital finance services (Pay Maya, GCash, ING) ...... F F
2 No
G
Grocery shopping service (Pasabuy) ........................... G
Z Z
Others, specify ________ ............................................

In the past twelve (12) months, did you or any of your household Yes ............................................................................. 1
(08)
members engage in purchasing goods and/or services online? No ............................................................................... 2

In the past twelve (12) months, did you or any of your household Yes ............................................................................. 1
(09) members engage in online work through an online platform (e.g.
Upwork, etc.)? No ............................................................................... 2 GO TO SECTION O

a. Desk Job (Upwork, OnlineJobs.ph) PhP

In the past twelve (12) months, how much is the total salaries/wages
(10) b. Transport Network Vehicle Service (TNVS) like Grab, Angkas PhP
received from online work through an online platform?
c. Others, specify: _______________ PhP

O. CRIME VICTIMIZATION
The next set of questions will ask about whether you and your household members were victimized by crime. This might be a sensitive topic but we encourage you to answer the questions
as it might help achieve peace and order in your community or Barangay.
FOR ALL HOUSEHOLD MEMBERS

Safe ............................................................................. 1
Somewhat Safe ............................................................ 2
How safe do you feel walking alone in your area (i.e. neighborhood or Somewhat Unsafe ........................................................ 3
(01)
village) at night? Unsafe ......................................................................... 4
I'm afraid to be alone .................................................... 5
Don’t Know ................................................................... 6

In the past twelve (12) months, were you or any of your household Yes .............................................................................. 1 GO TO 03
(02)
members became a victim of crime? No ............................................................................... 2 GO TO SECTION P

Version as of 30/08/2021 28 of 40 CBMS Form 2 HPQ

O. CRIME VICTIMIZATION
What crime/s was/were (NAME) a victim of? Who among your In the past twelve (12) Where did the most Was the crime What was the main
family members were months, how many recent crime/s reported to the police/ reason why crime was
Was the household member a victim of ____? victimized by any times did (NAME) happen? barangay? not reported to authori-
crime? became a victim/ ties?
experienced crime?
(Enter Line Number of
HH Member victimized 1 Yes Answer this if Code 2
by crime, 2 No in 07
IF ANSWER IN 03 IS
A-G, K AND Z, EN-
TER LINE NUMBER SEE CODES BELOW SEE CODES BELOW
OF HH MEMBER
VICTIMIZED BY
CRIME.

IF ANSWER IN 03 IS
H/I/J, SELECT ALL
HOUSEHOLD MEM-

(03) (04) (05) (06) (07) (08)

1 1 1 1 1
A Theft of personal property 1 Yes
2 2 2 2 2
(pickpocketing, other thefts) 2 No, go to B
3 3 3 3 3
1 1 1 1 1
B Robbery (theft by using vio- 1 Yes
2 2 2 2 2
lence) 2 No, go to C
3 3 3 3 3
1 1 1 1 1
C Psychological violence 1 Yes
2 2 2 2 2
(mobbing, stalking) 2 No, go to D
3 3 3 3 3
1 1 1 1 1
D Sexual offenses (sexual as- 1 Yes
2 2 2 2 2
sault, rape) 2 No, go to E
3 3 3 3 3
1 1 1 1 1
E Fraud (cheating, credit card 1 Yes
2 2 2 2 2
fraud, internet fraud) 2 No, go to F
3 3 3 3 3
1 1 1 1 1
1 Yes
F Corruption/bribery 2 2 2 2 2
2 No, go to G
3 3 3 3 3
1 1 1 1 1
1 Yes
G Exposure to illegal drugs 2 2 2 2 2
2 No, go to H
3 3 3 3 3

H Vehicle theft (motor vehicle, 1 1 1 1 1

1 Yes
car, motorcycle, bicycle; theft from 2 2 2 2 2
2 No, go to I
vehicles 3 3 3 3 3
1 1 1 1 1
I Housebreaking (domestic bur- 1 Yes
2 2 2 2 2
glary, attempted burglary) 2 No, go to J
3 3 3 3 3
1 1 1 1 1
J Vandalism (damage to cars, 1 Yes
2 2 2 2 2
graffiti) 2 No, go to K
3 3 3 3 3
1 1 1 1 1
1 Yes
K Assault and threat 2 2 2 2 2
2 No, go to Z
3 3 3 3 3
Z. OTHERS 1 Yes 1 1 1 1 1

__________________ 2 No, go to 2 2 2 2 2
SPECIFY SECTION P 3 3 3 3 3

(06) LOCATION OF THE CRIME (08) REASON FOR NOT REPORTING

1 Within the barangay 1 THREATENED

2 Outside the barangay but within municipality/city 2 AFRAID

3 Outside the municipality/city but within province 3 NO FINANCIAL SUPPORT

4 Outside the province 4 THINKS NO ONE WOULD LISTEN/BELIEVE

5 EMBARASSED/ASHAMED

9 OTHERS, SPECIFY:____

CBMS Form 2 HPQ 29 of 40 Version as of 30/08/2021

P. GOVERNMENT PROGRAMS
Now we would like to if any of household member received, benefitted from or a member of any government programs.
SOCIAL INSURANCE

(01) Does any member of your household (including (OFW) a (02.1) Who among the household (03) In the past 12 months, (04) In the past 12 months, who
dependent/beneficiary/member of any of the following social/ members are members of the (NAME did any member of your among the household members have
health insurance programs? OF SOCIAL/ HEALTH INSURANCE household avail/receive availed/received assistance/benefits/
PROGRAM)? benefits/grants/assistance/ payments from the (NAME OF
payment from (NAME OF SOCIAL/ HEALTH INSURANCE
SOCIAL HEALTH PROGRAM)?
ENTER LINE NUMBER INSURANCE PROGRAM)? ENTER LINE NUMBER

Yes ...1 (Go to 02.1) Yes …1 (Go to 04)

A. SSS
No …2 (Go to B) No …2 (Go to (B)
Yes … 1 (Go to 02.1) Yes …1 (Go to 04)
B. GSIS
No …. 2 (Go to C) No …2 (Go to C)
C. Overseas Workers Wel- Yes … 1 (Go to 02.1) Yes …1 (Go to 04)
fare Administration (OWWA) No …. 2 (Go to D) No …2 (Go to D)
D. Health/Medical Insurance
Yes … 1 (Go to 02.1) Yes …1 (Go to 04)
other than PhilHealth (e.g
No …. 2 (Go to E) No …2 (Go to E)
MediCard, Maxicare, etc.)
E. Life Insurance/Pre-need
Yes …1 (Go to 02.1) Yes …1 (Go to 04)
Insurance (e.g SunLife, Pru
No … 2 (Go to F) No …2 (Go to (F)
Life, St.Peter Life Plan, etc)
Yes …1 (Go to 02.1) Yes …1 (Go to 04)
F. PAGIBIG
No ….2 (Go to G) No …2 (Go to (G)
Yes …1 (Go to 02.1) Yes …1 (Go to 04)
G. PhilHealth
No ….2 (Go to 05) No …2 (Go to (05)

Note to EN: ASK EACH MEMBER IF 'YES '1' IN 01.G. (Philhealth

(02.2) What is the type of PAYING ............................ 1
Member only) Put the corresponding answer aligned with the Line
membership? NON-PAYING ................... 2
Number in 2.1 G. Philhealth

SOCIAL ASSISTANCE

(05) In the past 12 months, did any member of your household receive (06) Who among the household members received the (07) In the past 12 months, how
benefits/grants/assistance/payment from any of the following programs? benefits/grants/ assistance/payment from the (NAME OF THE many times did your household
PROGRAM)? receive benefits/grants/assistance/
payment from the (NAME OF THE
ENTER LINE NUMBER PROGRAM)?

A. Regular Conditional Cash Trans-

Yes ….1 (Go to 06)
fer - Pantawid Pamilyang Pilipino
No ….2 (Go to B)
Programs (4Ps)

B. Modified Conditional Cash

Yes …1 (Go to 06)
Transfer - Pantawid Pamilyang
No …2 (Go to C)
Pilipino Programs (4Ps)

C. Unconditional Cash Transfer Yes …1 (Go to 06)

(UCT) under tax Reform Program No …2 (Go to D)

D. Indigent Senior Citizen's Social Yes …1 (Go to 06)

Pension (SPISC of SocPen) No …2 (Go to E)

E. Individual Medical Assistance

Yes …1 (Go to 06)
Program (IMAP) under Philippine
No …2 (Go to F)
Charity Sweeptakes Office (PCSO)

F. Student Financial Assistance

Programs (StuFAP) other than Yes …1 (Go to 06)
Universal Access to Quality Tertiary No …2 (Go to G)
Education (UAQTE)

G. Emergency Shelter Assistance Yes …1 (Go to 06)

(ESA) No …2 (Go to H)

H. Housing program Yes …1 (Go to 06)

No …2 (Go to I)

I. Health assistance Yes …1 (Go to 06)

No …2 (Go to J)

J. DA Cash and Food Subsidy for Yes …1 (Go to 06)

Marginal Farmers and Fisherfolks No …2 (Go to 08)

Version as of 30/08/2021 30 of 40 CBMS Form 2 HPQ

P. GOVERNMENT PROGRAMS

GOVERNMENT FEEDING PROGRAM

(10) In the past 12 months, how

(09) Who among the household members benefitted/availed in
many times did your household
the feeding program?
(08) In the past 12 months, did receive benefits/grants/
any member of your household assistance/payment from the
Yes …1
receive assistance from any feeding program?
No …2, go to 11 ENTER LINE NUMBER
feeding program by the govern-
ment?

LABOR MARKET INTERVENTION

(11) In the past 12 months, did any member of your household benefit/ (12) Who among the household members benefitted/availed of (13) In the past 12 months, how
avail from any of the following programs/assistance? the (NAME OF PROGRAM/ ASSISTANCE)? many times did your household
receive benefits/grants/ assistance/
ENTER LINE NUMBER payment from the (NAME OF THE
PROGRAM)?

A. Micro Enterprise Development Yes …1, go to 12

Track / SLP No …2, go to B

B. Employment Facilitation Track / Yes …1, go to 12

SLP No …2, go to C

C. Integrated Livelihood/Kabuhayan Yes …1, go to 12

Program under Department of Labor and
Employment (DOLE) No …2, go to D

Yes …1, go to 12
D. Cash for Work
No …2, go to E

Yes …1, go to 12
E. Food for Work
No …2, go to F

F. Community-Based Employment Yes …1, go to 12

Program No …2, go to 14

AGRICULTURE AND FISHERIES

(14) In the past 12 months, did any member of your household receive (15) Who among the household members received the bene- (16) In the past 12 months, how
benefits/grants/assistance/payment from any of the following programs? fits/grants/ assistance/payment from the (NAME OF THE many times did your household
PROGRAM)? receive benefits/grants/ assistance/
payment from the (NAME OF THE
ENTER LINE NUMBER PROGRAM)?

A. Agrarian Reform Community Devel- Yes …1, go to 15

opment Program (ARCDP) No …2, go to B

B. Partnership Against Hunger and Yes …1, go to 15

Poverty No …2, go to C

C. Climate Resilient Farm Productivity Yes …1, go to 15

Support No …2, go to D

D. Community Potable Water, Sanita- Yes …1, go to 15

tion, Hygiene No …2, go to E

E. Village Level Farm- focused Enter- Yes …1, go to 15

prise Development (VLFED) No …2, go to F

F. Linking Smallholder Farmers to Yes …1, go to 15

Markets (LINKSFARMS) No …2, go to G

G. Convergence Livelihood Assistance

Yes …1, go to 15
for Agrarian Reform Beneficiary Project
(CLAAP) No …2, go to H

H. Production support services (e.g. Yes …1, go to 15

seeds, fertilizer, Pesticides, etc.) No …2, go to I

I. Production, post-production, posthar- Yes …1, go to 15

vest and irrigation facilities No …2, go to J

J. Capacity development/training/
Yes …1, go to 15
technology transfer programs on agricul-
ture and fisheries No …2, go to 17

CBMS Form 2 HPQ 31 of 40 Version as of 30/08/2021

P. GOVERNMENT PROGRAMS
SOCIAL ASSISTANCE PROGRAM UNDER BAYANIHAN ACT
(17) In the past 12 months, did any member of your household receive (18) Who among the household members received the bene- (19) In the past 12 months, how
benefits/grants/assistance/payment from any of the following programs? fits/grants/ assistance/payment from the (NAME OF THE many times did your household
PROGRAM)? receive benefits/grants/assistance/
payment from the (NAME OF THE
ENTER LINE NUMBER PROGRAM)?
A. Social Amelioration Program (SAP) Yes …1, go to 18
under DSWD No …2, go to B
B. DOLE TUPAD “Barangay Ko, Buhay
Yes …1, go to 18
Ko” (Tulong Panghanapbuhay sa Ating
Disadvantaged/Displaced Workers) No …2, go to C

C. DOLE COVID-19 Adjustment

Yes …. 1, go to 18
Measures Program (CAMP) (One-time
financial support to employed workers) No ….2, go to D

D. DOLE AKAP (Financial assistance

Yes …1, go to 18
provided to displaced land-based and
sea-based Filipino workers) No …2, go to E

E. DTI Livelihood Seeding Program and Yes …1, go to 18

Negosyo Serbisyo sa Barangay No …2, go to F
F. DA Rice Farmers Financial Assistance
Yes …1, go to 18
Program (RFFA) and Financial Subsidy
to Rice Farmers (FSRF) Program No …2, go to G

G. DSWD Relief Assistance Yes …1, go to 18

No …2, go to H
H. Relief Assistance from the Govern- Yes …1, go to 18
ment (other than DSWD) No …2, go to I
I. Relief Assistance other than from Yes …1, go to 18
Government No …2, go to J
J. Bayanihan 2 Assistance to Health Yes …1, go to 18
Workers No …2, go to K

K. Bayanihan 2 Financial relief to Yes …1, go to 18

ARBs No …2, go to L

L. Bayanihan 2 Financial Assistance to Yes …1, go to 18

Students No …2, go to M
M. Bayanihan 2 Financial Assistance
Yes …1, go to 18
to Teaching and Non-teaching Person-
No …GO TO SECTION Q
nel

Q. WATER, SANITATION, AND HYGIENE

The next set of questions will ask about the source of drinking and non-drinking water of your household, the kind of toilet that your using and your handwashing facility.
COMMUNITY WATER SYSTEM PIPED INTO:
DWELLING .......................................................... 01 GO TO 03
YARD/PLOT ......................................................... 02
PUBLIC TAP ........................................................ 03 ____________
POINT SOURCE: SPECIFY
PROTECTED WELL/TUBE WELL/BOREHOLE 04
(01) What is your household's main source of water supply? UNPROTECTED (OPEN DUG WELL) ................. 05
DEVELOPED SPRING ........................................ 06
UNDEVELOPED SPRING ................................... 07
RIVER/STREAM/POND/LAKE/DAM .................... 08
RAINWATER ........................................................ 09 GO TO 03
TANKER TRUCK/PEDDLER/NEIGHBOR ........... 10 GO TO 03
OTHERS, SPECIFY: ____________ ..................... 99

IF ANSWER TO 01 IS ANY OF THE CODES 02 TO 08: How far is this

(02) METER
water source from your house?

PIPED WATER
PIPED INTO DWELLING ..................................... 11 GO TO 10
PIPED TO YARD/PLOT ....................................... 12 GO TO 10
PIPED TO NEIGHBOR ........................................ 13 GO TO 05
PUBLIC TAP/STAND PIPE ................................. 14 GO TO 05
TUBED WELL/BOREHOLE ................................. 21 GO TO 05
DUG WELL
PROTECTED WELL ............................................ 31 GO TO 05 ____________
UNPROTECTED WELL ....................................... 32 GO TO 05 SPECIFY
What is the main source of drinking water used by members of your SPRING
households? PROTECTED SPRING ........................................ 41 GO TO 05
(03) UNPROTECTED SPRING ................................... 42 GO TO 05
If unclear, probe to identify the place from which members of this RAINWATER ............................................................. 51 GO TO 05
household most often collect drinking water (collection point) TANKER-TRUCK ...................................................... 61 GO TO 05
CART WITH SMALL TANK ....................................... 71 GO TO 05
WATER REFILLING STATION ................................. 72
SURFACE WATER (RIVER, DAM, LAKE, POND, STREAM,
CANAL, IRRIGATION CHANNEL) ........... 81 GO TO 05
PACKAGED WATER
BOTTLED WATER ............................................... 91
SACHET WATER ................................................. 92
OTHERS, SPECIFY: ____________ .......................... 99 GO TO 05

Version as of 30/08/2021 32 of 40 CBMS Form 2 HPQ

Q. WATER, SANITATION, AND HYGIENE
PIPED WATER
PIPED INTO DWELLING ..................................... 11
PIPED TO YARD/PLOT ....................................... 12
PIPED TO NEIGHBOR ........................................ 13
PUBLIC TAP/STAND PIPE .................................. 14
TUBED WELL/BOREHOLE ................................. 21 ____________
DUG WELL SPECIFY
PROTECTED WELL ............................................ 31
UNPROTECTED WELL ....................................... 32
What is the main source of water used by members of your household SPRING
for other purposes such as cooking and handwashing? PROTECTED SPRING ........................................ 41
(04)
If unclear, probe to identify the place from which members of this UNPROTECTED SPRING ................................... 42
household most often collect water for other purposes RAINWATER ............................................................. 51
TANKER-TRUCK ...................................................... 61
CART WITH SMALL TANK ....................................... 71
WATER REFILLING STATION ................................. 72
SURFACE WATER (RIVER, DAM, LAKE, POND,
STREAM, CANAL, IRRIGATION CHANNEL ............ 81
PACKAGED WATER
BOTTLED WATER ............................................... 91
SACHET WATER ................................................. 92
OTHERS, SPECIFY: ____________ .......................... 99

IN OWN DWELLING ................................................. 1 GO TO 10

(05) Where is the source of drinking water located? IN OWN YARD/PLOT ................................................. 2 GO TO 10
ELSEWHERE ............................................................ 3

MEMBERS DO NOT COLLECT .................................. 000 GO TO 10

How long does it take for members of your household to go there, get
(06) NUMBER OF MINUTES ............................................. ___
water, and come back?
DON'T KNOW ............................................................. 998

(07) How far is this source of drinking water from your house? METER …………………………………………………..

Who usually goes to this source to collect the water for your LINE NUMBER ______________________________
(08) household?
LAST NAME, FIRST NAME, M.I.
WRITE CODE “96” IF THE ANSWER IS NOT HH MEMBER

Since last (DAY OF THE WEEK), how many times has this person NUMBER OF TIMES…
(09)
collected water? DON’T KNOW …. __

YES, AT LEAST ONCE ............................................... 1

In the last month, has there been any time when your household did
(10) NO, ALWAYS SUFFICIENT ........................................ 2 GO TO 12
not have sufficient quantities of drinking water?
DON’T KNOW ............................................................. 8 GO TO 12

WATER NOT AVAILABLE FROM SOURCE .............. 1

WATER TOO EXPENSIVE ......................................... 2
What was the main reason that you were unable to access drinking
(11) SOURCE NOT ACCESSIBLE ..................................... 3
water in sufficient quantities when needed?
DON'T KNOW ............................................................. 8 ____________
OTHERS, SPECIFY: ___________ ............................ 9 SPECIFY

YES ............................................................................. 1
(12) Do you do anything to the water to make it safer to drink? NO ............................................................................... 2 GO TO 14
DON’T KNOW ............................................................. 8 GO TO 14

BOILED IT ................................................................... A
ADD BLEACH/CHLORINE .......................................... B
What do you usually do to make the water safer to drink?
STRAIN IT THROUGH A CLOTH ............................... C
USE WATER FILTER (CERAMIC, SAND,
PROBE:
(13) COMPOSITE, ETC.) ............................................... D ____________
Anything else?
SOLAR DISINFECTION ……………………………… E SPECIFY
LET IT STAND AND SETTLE ..................................... F
RECORD ALL METHODS MENTIONED
DON'T KNOW ............................................................. X
OTHERS, SPECIFY: _____________ ........................ Z

FLUSH/POUR FLUSH
FLUSH TO PIPED SEWER SYSTEM .................... 11 GO TO 18
FLUSH TO SEPTIC TANK ..................................... 12
FLUSH TO PIT LATRINE ....................................... 13 GO TO 16
______________
FLUSH TO OPEN DRAIN ...................................... 14 GO TO 18 SPECIFY
FLUSH TO DK WHERE ......................................... 15 GO TO 18
What kind of toilet facility do members of your household usually used?
PIT LATRINE
IF 'FLUSH' OR 'POUR FLUSH', PROBE:
VENTILATED IMPROVED LATRINE ..................... 21 GO TO 16
(14) Where does it flush to?
PIT LATRINE WITH SLAB ..................................... 22 GO TO 16
IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO
PIT LATRINE WITHOUT SLAB/OPEN PIT ............ 23 GO TO 16
OBSERVE FACILITY.
COMPOSTING TOILET .............................................. 31 GO TO 16
BUCKET ...................................................................... 41 GO TO 18
HANGING TOILET/HANGING LATRINE .................... 51 GO TO 18
PUBLIC TOILET .......................................................... 71 GO TO 22
NO FACILITY/BUSH/FIELD ........................................ 95 GO TO 22
OTHERS, SPECIFY: __________ .............................. 99 GO TO 18

CBMS Form 2 HPQ 33 of 40 Version as of 30/08/2021

Q. WATER, SANITATION, AND HYGIENE

SEWER LINES ........................................................... 1

SOAKAGE PIT ............................................................ 2
MUNICIPALITY/CITY DRAINAGE .............................. 3
DIRECTLY TO BODY OF WATER-CREEK, RIVER, ____________
(15) Where does the outlet of the septic tank go?
LAKE, COASTAL WATER ..................................... 4 SPECIFY
NO OUTLET OR UNDERGROUND .......................... 5
DON'T KNOW ............................................................. 8
OTHERS, SPECIFY: _________ ................................ 9

YES, EMPTIED
WITHIN THE LAST 5 YEARS ................................ 1
MORE THAN 5 YEARS AGO ................................ 2
DON'T KNOW WHEN ................................................. 3
(16) Has your (ANSWER FROM 14) ever been emptied? NO, NEVER EMPTIED ............................................... 4 GO TO 18
NO, NEW TOILET HAS BEEN CONSTRUCTED ....... 5 GO TO 18
CLOSED/COVERED AND CONSTRUCTED A NEW
LATRINE/SEPTIC TANK ........................................ 6 GO TO 18
DON'T KNOW ............................................................. 8 GO TO 18

REMOVED BY SERVICE PROVIDER

TO A TREATMENT PLANT/REMOVED BY
SERVICE PROVIDER ....................................... 1
BURIED IN A COVERED PIT ................................. 2
The last time it was emptied, where were the contents emptied to?
TO DON’T KNOW WHERE .................................... 3
(17) REMOVED BY HOUSEHOLD/NEIGHBOR
PROBE:
BURIED IN A COVERED PIT ................................ 4 ____________
Was it removed by a service provider?
TO UNCOVERED PIT, OPEN GROUND, WATER SPECIFY
BODY OR ELSEWHERE .................................. 5
DON'T KNOW ............................................................. 8
OTHER (specify) __________ .................................... 9

IN OWN DWELLING ................................................... 1

(18) Where is this toilet facility located?
IN OWN YARD/PLOT .................................................. 2

Do you share this facility with others who are not members of your YES ............................................................................. 1
(19)
household? NO ............................................................................... 2 GO TO 22
How many household's in total use this toilet facility, including your own
(20) NUMBER OF HOUSEHOLDS
household?

SHARED WITH KNOWN HOUSEHOLDS (NOT

Do you share this facility only with members of other households that
(21) PUBLIC) ................................................................. 1
you know or is the facility open to the use of the general public?
SHARED WITH GENERAL PUBLIC ........................... 2

SEGREGATING WASTE ........................................... A A

LETTING GARBAGE TRUCK COLLECT WASTE .... B B
RECYCLING/REUSING AT HOME ............................ C C
SELLING/GIVING AWAY RECYCLABLES ................ D D
In what ways does your household dispose its solid wastes? COMPOSTING ........................................................... E E
(22) BURNING ................................................................... F F
1 Yes
DUMPING IN PIT WITH COVER ............................... G G
2 No
DUMPING IN PIT WITHOUT COVER ........................ H H
THROWING IN UNINHABITED LOCATIONS ............ I I
OTHERS, SPECIFY; ________ .................................. Z Z
____________
SPECIFY

OBSERVED
FIXED FACILITY OBSERVED (SINK/TAP)
IN DWELLING ................................................... 1
We would like to learn about where members of this household wash IN YARD/PLOT ................................................. 2
their hands. MOBILE OBJECT OBSERVED (BUCKET/JUG/
(23) Can you please show me where members of your household most KETTLE) ............................................................ 3
often wash their hands? NOT OBSERVED
RECORD RESULT AND OBSERVATION NO HANDWASHING PLACE IN DWELLING/
YARD/PLOT ...................................................... 4 GO TO 27
NO PERMISSION TO SEE .................................... 5 GO TO 26
OTHER REASON, SPECIFY: _______ ................. 9 GO TO 27

OBSERVE PRESENCE OF WATER AT THE PLACE FOR

HANDWASHING.
WATER IS AVAILABLE .............................................. 1
(24) VERIFY BY CHECKING THE TAP/PUMP, OR BASIN, BUCKET,
WATER IS NOT AVAILABLE ...................................... 2
WATER CONTAINER OR SIMILAR OBJECTS FOR PRESENCE OF
WATER

Version as of 30/08/2021 34 of 40 CBMS Form 2 HPQ

Q. WATER, SANITATION, AND HYGIENE

IS SOAP OR DETERGENT PRESENT AT THE PLACE FOR YES, PRESENT .......................................................... 1 GO TO 30

(25)
HANDWASHING? NO, NOT PRESENT ................................................... 2 GO TO 28

FIXED FACILITY (SINK/TAP)

IN DWELLING ........................................................ 1
Where do you or other members of your household most often wash IN YARD/PLOT ...................................................... 2
your hands? MOBILE OBJECT (BUCKET/JUG/
(26)
KETTLE) ....................................................... 3
RECORD RESULT AND OBSERVATION NO HANDWASHING PLACE IN DWELLING/YARD/
____________
PLOT ....................................... 4 SPECIFY
NOT OBSERVED - REASON, SPECIFY: _________ 9

YES ............................................................................. 1
(27) Do you have available water in your house for washing hands?
NO ............................................................................... 2

YES ............................................................................. 1
(28) Do you have any soap or detergent in your house for washing hands?
NO ............................................................................... 2
GO TO SECTION R.

YES ............................................................................. 1
(29) Can you please show it to me?
NO, NOT SHOWN ...................................................... 2 GO TO SECTION R.
HOUSING

BAR OR LIQUID SOAP .............................................. A

RECORD YOUR OBSERVATION
DETERGENT (POWDER/LIQUID/PASTE) ................ B
(30) RECORD THE RESPONSE (IF NOT OBSERVE)
ASH/SOIL/SAND ........................................................ C ____________
ENCIRCLE ALL THAT APPLY
OTHERS, SPECIFY: __________ ............................ D SPECIFY

R. HOUSING
The last set of questions will ask about the characteristics and amenities of your housing unit and your household conveniences.

Single house ................................................................ 1

Duplex .......................................................................... 2
Apartment/accessoria/rowhouse ................................. 3
Condominium/Condotel ............................................... 4
Other multi-unit residential .......................................... 5 ____________
What is the type of building occupied by your household?
Commercial/industrial/agricultural (e.g. office, factory, SPECIFY
(01) barn) ........................................................................ 6
ANSWER THROUGH OBSERVATION. IF DOUBTFUL, ASK THE
RESPONDENT. Institutional living quarter (e.g. hotel, hospital,
convent, jail) ............................................................ 7
None (e.g. homeless, cart) .......................................... 8 END INTERVIEW
Other types of building (e.g. bus/trailer, boat, tent),
specify:__________ ............................................... 9 GO TO 12

(02) How many floors are there in this building? NUMBER OF FLOORS …………………………………

Galvanized iron/aluminum ........................................... 1

Concrete/clay tile ......................................................... 2
What is the main construction material of the roof of this building? Half galvanized iron and half concrete ......................... 3
Wood/bamboo ............................................................. 4
(03)
ANSWER THROUGH OBSERVATION. IF DOUBTFUL, ASK THE Cogon/nipa/anahaw ..................................................... 5
RESPONDENT. Asbestos ...................................................................... 6 _______________
Makeshift/salvaged/improvised materials .................... 7 SPECIFY
Others, specify _____________ .................................. 9

Concrete ...................................................................... 1
Steel ............................................................................ 2
What is the construction material for the roof framing of this housing Wood ........................................................................... 3
(03.1)
unit? Bamboo ....................................................................... 4
_______________
None ............................................................................ 5 SPECIFY
Others, specify _____________ ................................. 9

Concrete/brick/stone .................................................... 01
Wood ........................................................................... 02
Half concrete/brick/stone and half wood ...................... 03
Galvanized iron/aluminum ........................................... 04
Bamboo/sawali/cogon/nipa .......................................... 05
What is the construction material of the outer walls of this building?
Asbestos ...................................................................... 06
(04) Glass ............................................................................ 07
ANSWER THROUGH OBSERVATION. IF DOUBTFUL, ASK THE _______________
Makeshift/salvaged/improvised materials .................... 08
RESPONDENT. SPECIFY
None ............................................................................ 09
Concrete hollow blocks ............................................... 10
Concrete hollow blocks/wood ...................................... 11
Shear walls .................................................................. 12
Others, specify _____________ .................................. 99

CBMS Form 2 HPQ 35 of 40 Version as of 30/08/2021

R. HOUSING

Ceramic tile/marble/granite .......................................... 1

Cement/brick/stone ...................................................... 2
Wood plank .................................................................. 3
Wood tile/parquet ......................................................... 4
(05) What is the finishing material of the floor of this housing unit?
Vinyl/carpet tile ............................................................ 5
_______________
Linoleum ...................................................................... 6 SPECIFY
None ............................................................................ 7
Others, specify _____________ .................................. 9

Concrete ...................................................................... 1
Wood ........................................................................... 2
Coconut lumber ........................................................... 3
(06) What is the main construction material of the floor of this housing unit? Bamboo ....................................................................... 4
Earth/sand/mud ........................................................... 5
_______________
Makeshift/salvaged/improvised materials .................... 6 SPECIFY
Others, specify _____________ .................................. 9

(07) What is the estimated floor area of this housing unit? IN SQUARE METERS

Wood ........................................................................... 01
Wood Column Only ...................................................... 02
Concrete ...................................................................... 03
Steel ............................................................................. 04
Bamboo ....................................................................... 05
Light Metal ................................................................... 06
Concrete GF + Wood 2F .............................................. 07
(08) What is the frame material of this housing unit? Concrete Column Only ………………………................ 08
Concrete Column Only / No Concrete Beam 1F + _______________
Wood 2F ...................................................................... 09 SPECIFY
Concrete Column Only, Wooden Beam ...................... 10
Concrete Column Only, Steel Beam ........................... 11
Steel Column, Wooden Beam .................................... 12
None ............................................................................ 13
Others, specify _____________ .................................. 99

(09) How many bedrooms does this housing unit have? NUMBER OF BEDROOMS

Own or owner-like possession of the house and lot .... 1

Own house, rent lot ...................................................... 2
Own house, rent-free lot with consent of owner .......... 3
What is the tenure status of the housing unit and lot occupied by this
(10) Own house, rent-free lot without consent of owner ..... 4
household?
Rent house/room, including lot .................................... 5
Rent-free house and lot with consent of owner ........... 6
Rent-free house and lot without consent of owner ...... 7

(10.1) When was the building constructed? Indicate year of construction ……………………………

By your own estimate, how much is the imputed rent per month for the
(11) IMPUTED RENT ...................................................................
house and/or lot?
AMOUNT

Yes ............................................................................... 1
(12) Is there any electricity in the dwelling place?
No ................................................................................ 2 GO TO 14

What is/are the source/s of electricity in the dwelling place? Electric company ......................................................... A
Generator ..................................................................... B
(13) 1 Yes Solar ............................................................................ C
2 No Battery ......................................................................... D
Others, specify: ________ ........................................... Z ____________
SPECIFY

Electricity ..................................................................... 1
Kerosene (gaas) .......................................................... 2
Liquefied petroleum gas (LPG) .................................... 3
(14) What type of fuel does this household use for lighting? Oil (vegetable, animal, and others) .............................. 4 ____________
SPECIFY
Solar panel/solar lamp ................................................. 5
None ............................................................................ 6
Others, specify _____________ .................................. 9

Version as of 30/08/2021 36 of 40 CBMS Form 2 HPQ

R. HOUSING

Electricity ..................................................................... 1
Kerosene (gaas) .......................................................... 2
Liquefied petroleum gas (LPG) .................................... 3
What type of fuel does this household use most of the time for
(15) Charcoal ...................................................................... 4
cooking?
Wood ........................................................................... 5
____________
None ............................................................................ 6 SPECIFY
Others, specify _____________ .................................. 9

HOUSEHOLD CONVENIENCES
REFRIGERATOR/FREEZER .................................. A A
STOVE WITH OVEN/GAS RANGE ........................ B B
MICROWAVE OVEN .............................................. C C
WASHING MACHINE ............................................. D D
AIR CONDITIONER ................................................ E E
ELECTRIC FAN AND OTHER COOLING
EQUIPMENT ...................................................... F F
ICT DEVICES
RADIO/RADIO CASSETTE (AM, FM, AND
TRANSISTOR) ................................................... G G
TELEVISION ........................................................... H H
How many of each of the following items does the household own?
CD/DVD/VCD PLAYER .......................................... I I
(16)
AUDIO COMPONENT/STEREO SET/KARAOKE/
IF THE ANSWER IN "H. TELEVISION" IS 00, GO TO 18
VIDEOKE ........................................................... J J
LANDLINE/WIRELESS TELEPHONE .................... K K
MOBILE PHONE ..................................................... L L
TABLET .................................................................. M M
PERSONAL COMPUTER (DESKTOP, LAPTOP,
NOTEBOOK, NETBOOK, AND OTHERS) ........ N N
VEHICLES
CAR/VAN/JEEP/TRUCK ......................................... O O
MOTORCYCLE/MOTOR SCOOTER/TRICYCLE ... P P
BICYCLE/PEDICAB ................................................ Q Q
MOTORIZED BOAT/BANCA .................................. R R
NONMOTORIZED BOAT/BANCA .......................... S S

Cable TV (CATV) ........................................................ A

Direct-to-Home (DTH) Satellite Services .................... B
(17) Does this household have any of the following television services? IPTV/Smart TV ........................................................... C
Digital Terrestrial TV (DTT) ......................................... D
Analog Television ....................................................... E

CARABAO ................................................................... A
CATTLE ......................................................... B
HORSES ...................................................................... C
SWINE ......................................................................... D
(18) How many of the following animals does this household own?
GOATS ........................................................................ E
SHEEP ......................................................................... F
CHICKENS/DUCKS/POULTRY ................................... G
OTHER SPECIFY: __________ ................................. Z
____________
SPECIFY

CBMS Form 2 HPQ 37 of 40 Version as of 30/08/2021

S. REFUSAL QUESTIONS
ASK TO THOSE HOUSEHOLDS WHO REFUSED TO BE INTERVIEWED
The last set of questions will ask about the characteristics and amenities of your housing unit and your household conveniences.

(01) Name of Respondent (Last Name, First Name)

Member of the Family/Occupant of the Housing Unit 1

Nonrelative/Household Staff (e.g. helper
(02) How are you related to the occupants of the housing unit/household? kasambahay, security guard) ...................................... 2
Neighbor ...................................................................... 3
Other not elsewhere classified .................................... 4

1 2 3 4 5 6 7 8 9 10
Imagine a ladder with ten steps. The first represents the poorest in Poorest Richest
(03) society and the tenth represents the richest. On what step of the ladder
would the household be?

TO BE OBSERVED BY ENUMERATORS
Single house ................................................................ 1
Duplex ......................................................................... 2
Apartment/accessoria/rowhouse ................................. 3
Condominium/Condotel ............................................... 4
What is the type of building occupied by your household? Other multi-unit residential ........................................... 5
Commercial/industrial/agricultural (e.g. office, factory,
(04)
ANSWER THROUGH OBSERVATION. IF DOUBTFUL, ASK THE barn) ....................................................................... 6
RESPONDENT. Institutional living quarter (e.g. hotel, hospital,
convent, jail) ............................................................ 7
None (e.g. homeless, cart) .......................................... 8 END OF INTERVIEW
Other types of building (e.g. bus/trailer, boat, tent),
specify:__________ ................................................ 9 END OF INTERVIEW

(05) How many floors are there in this building? NUMBER OF FLOORS

Galvanized iron/aluminum ........................................... 1

Concrete/clay tile ......................................................... 2
What is the main construction material of the roof of this building? Half galvanized iron and half concrete ......................... 3
Wood/bamboo ............................................................. 4
(06)
ANSWER THROUGH OBSERVATION. IF DOUBTFUL, ASK THE Cogon/nipa/anahaw ..................................................... 5
____________
RESPONDENT. Asbestos ...................................................................... 6 SPECIFY
Makeshift/salvaged/improvised materials .................... 7
Others, specify _____________ .................................. 9
Concrete/brick/stone .................................................... 01
Wood ........................................................................... 02
Half concrete/brick/stone and half wood ...................... 03
Galvanized iron/aluminum ........................................... 04
Bamboo/sawali/cogon/nipa .......................................... 05
What is the construction material of the outer walls of this building?
Asbestos ...................................................................... 06
(07) Glass ............................................................................ 07
ANSWER THROUGH OBSERVATION. IF DOUBTFUL, ASK THE ____________
Makeshift/salvaged/improvised materials .................... 08 SPECIFY
RESPONDENT.
None ............................................................................ 09
Concrete hollow blocks ............................................... 10
Concrete hollow blocks/wood ...................................... 11
Shear walls .................................................................. 12
Others, specify _____________ .................................. 99
Ceramic tile/marble/granite .......................................... 1
Cement/brick/stone ...................................................... 2
Wood plank .................................................................. 3
Wood tile/parquet ......................................................... 4 ____________
(08) What is the finishing material of the floor of this housing unit? SPECIFY
Vinyl/carpet tile ............................................................ 5
Linoleum ...................................................................... 6
None ............................................................................ 7
Others, specify _____________ .................................. 9
Concrete ...................................................................... 1
Wood ........................................................................... 2
Coconut lumber ........................................................... 3 ____________
SPECIFY
(09) What is the main construction material of the floor of this housing unit? Bamboo ....................................................................... 4
Earth/sand/mud ........................................................... 5
Makeshift/salvaged/improvised materials .................... 6
Others, specify _____________ .................................. 9

(10) What is the estimated floor area of this housing unit? IN SQUARE METERS

Version as of 30/08/2021 38 of 40 CBMS Form 2 HPQ

 ENUMERATOR’S NOTE

CBMS Form 2 HPQ 39 of 40 Version as of 30/08/2021

 COMPUTATION SHEET
NAME OF RESPONDENT: ______________________________

SECTION F. FAMILY INCOME

Family Family Family Family Family
SOURCES OF INCOME Member 1 Member 2 Member 3 Member 4 Member 5 Total

From Regular and Seasonal Employment

Salaries and wages from regular and seasonal employment
Commissions, tips, bonuses, family and clothing allowance, transportation and repre-
sentation allowance and honoraria
Other forms of compensation
From Entrepreneurial Activities
Net receipts derived from the operation of family operated enterprises/activities

Net receipts derived from the operation of practice of a profession or trade

From Other Sources of Family’s Income
Net share of crops, fruits, and vegetables produced, aquaculture products harvested
or livestock and poultry raised by other households
Cash receipts, gifts, support, relief, and other forms of assistance from abroad
Pantawid Pamilyang Pilipino Program (4Ps)
Social Pension for Indigent Senior Citizen
Social Amelioration Program (SAP) to Individuals in Crisis Situation
Other cash receipts, support, assistance, and relief from domestic sources
Dividend from investments
Rentals received from non-agricultural lands, buildings, spaces, and other properties
Interests (Interest from bank deposits, interest from loans extended to other families)
Other source of income, specify: _________

TOTAL
H. ENTREPRENEURIAL AND FAMILY SUSTENANCE ACTIVITIES

Amount
Item
In Philippine Peso (PhP)
Food Consumed at Home
a Bread and cereals
b Meat (e.g. fresh/chilled/frozen beef, pork, chicken, and other meat; edible offals; preserved and processed meat)
c Fish and seafood (fresh, chilled or frozen; dried, smoked or salted; canned or bottled)
d Milk, cheese and eggs
e Oils and fats (e.g. butter, margarine, corn/coconut and other edible oils)
f Fruits (fresh, dried/preserved) and nuts
g Vegetables
h Sugar, jam, honey, chocolate, and confectionery (e.g. ice cream/sorbet/edible ice, chewing gum, candies, pastilles, meringue,
bukayo, etc.)
i Food products not elsewhere classified (e.g. salt, spices and culinary herbs, sauces, condiments and seasonings, vinegar,
broth, soup stock, baby food, coffeemate)
j Coffee, tea and cocoa
k Mineral water, softdrinks, fruit and vegetable juices
Food Regularly Consumed Outside
l Food regularly bought and eaten by the family members outside the home like snacks, lunch and others (e.g. food bought
and eaten in carinderia/cafeteria during lunch/snacks in the office)

m Cooked food bought outside the home but eaten at home (e.g. FoodPanda and Grab Food deliveries or food takeout or
delivery for usual merienda/snacks/ breakfast/lunch/dinner at home)

n Daily allowance for snacks and meals at school of members of the household who are attending school
Total Family's Average Weekly Food Consumption In Philippine Peso (PhP)
OTHER COMPUTATION/S

NAME AND SIGNATURE OF ENUMERATOR

Version as of 30/08/2021 40 of 40 CBMS Form 2 HPQ