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3.-2024-CBMS Form-3 Waiver English

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Kevin Avalon Yap
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344 views

3.-2024-CBMS Form-3 Waiver English

Uploaded by

Kevin Avalon Yap
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CBMS FORM 3

Approval Number: PSA-2419-03 Republic of the Philippines


Expiry Date: 30 April 2025
Philippine Statistics Authority

COMMUNITY-BASED MONITORING SYSTEM


HOUSEHOLD PROFILE QUESTIONNAIRE
(CONSENT FORM/WAIVER)

In consideration of my participation in the Community-Based Monitoring System (CBMS) pursuant to Republic Act No.
11315, I hereby state the following:

1. I understand that CBMS is a tool developed to collect information intended to identify the extent of poverty at the
local level, determine its causes, serve as guide for formulating appropriate policies and programs, identify eligible
beneficiaries, and assess the impact of pertinent policies and programs.

2. I understand that my information is collected to generate data necessary to the foregoing purposes of the CBMS.

3. I understand that the PSA and the city/municipal local government will use my personal data and my household’s
personal data, including our information on Philippine Identification Card, address, among others, for their internal
purposes and official mandates (e.g., generation of official statistics and databases/registries).

4. I hereby AGREE and AUTHORIZE the PSA and city/municipal local government to share my personal data and
my household’s personal data to the appropriate national government agencies which provide social protection
programs for the households in the community such as the Department of Social Welfare and Development
(DSWD).

5. I fully understand that other than the purposes above, all the information collected will remain confidential and will
not be used against me or to any of my household member, pursuant to the CBMS law and the Data Privacy Act
of 2012.

6. Finally, I understand that my consent is not, in any way, a waiver of my rights as data subject under the Data
Privacy Act of 2012.

I have carefully read and fully understand the foregoing terms, and have freely, knowingly, and voluntarily signed this form
on behalf of the members of my household.

Signature over Printed Name of Respondent/


Authorized Representative of Respondent: _________________________________________________________
Last Name, First Name, M.I.

_________________________________________________________
Date Signed:
(MM/DD/YYYY)
--------------------------------------------------------------------------------------------------------------------------------------------------------------
TO BE ACCOMPLISHED BY CBMS HIRED PERSONNEL
Acknowledged by:

ENUMERATOR TEAM SUPERVISOR


Signature Over Printed Name Signature Over Printed Name Date:
Date:
(MM/DD/YYYY) (MM/DD/YYYY)
CITY/
PROV/HUC BRGY EA BSN HUSN HSN
MUN

LINE NUMBER OF RESPONDENT

LINE NUMBER OF SIGNATORY

Did the respondent sign the waiver?


1 Yes, END 1
Q1
2 No (GO TO Q2)

What is the main reason why the respondent did not sign the waiver?
1 Not interested in availing government social protection programs
2 Concern on security
Q2
3 Prefer not to answer
SPECIFY
9 Others, specify:

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