CIVIC WELFARE TRAINING SERVICE

NATIONAL SERVICE TRAINING PROGRAM

Civic Welfare Service Unit

School________________________________ Location________________________

Written Exercise No. 9

NEEDS ASESSMENT SURVEY FORM

Name of Household_________________________________ Gender_____ Age_____

Address______________________________________________________

A. Description of Barangay
I. Demography
No. of Person living in the house_____________
Gender distribution: Male______ Female______
Ethnic composition (by mother tongue of households)
Tagalog_____ Ilocano_____ Bicolano_____
Ilongo_____ Pampagano_____ Pangasinense_____
Other_____
Religious affiliation:
Roman Catholic_____ Protestant_____
Iglesia ni Cristo_____ Saksi ni Jehovah_____
Born Again/Renewed Christian_____
Aglipayan_____ Islam_____
Other_____
II. Economy
Residence is made of:
Concrete_____ Timber_____
Concrete/Timber_____ Other_____
House is Owned_____ Rented_____
Lot is Owned_____ Rented_____ Other_____
Lot area_____square meters
Production
Agricultural? _____ If yes, what type of plants/crops?
Fishing? _____
Livestock:
Animal raised? _______________________
Average number/household? ____________
Reason for raising animals?
_______________________________________________________

Other______________________________________
Average household/income/monthly/family (approximate)
Below P 6,000:_____ P 9,001-P10,000:_____
 P 6,001-7,000:_____ P 10,001-11,000:_____
P 7,001-8,000:_____ P 11,001-12,000:_____
P 8,001-9,000:_____ P 12,001-13,000:_____
Above 13,001:_____
III. Transportation and Communication
Means of transportation (check as many items apply)

Tricycle_____ Jeepney_____
Bus_________ Train_______
Boat________ Other_______
Short description of transportation system?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

IV. Educational and Health

Educational attainment (approximate)
No formal education______________
With elementary education________
With secondary education_________
With vocational non-degree________
With college degree_______________
Other___________________________
Health
Are the following available?
Clinic_____ Physician_____
Nurse_____ Midwife______
Other health care professional________________
Short description of the education and health conditions of
community____________________________________________
______________________________________________________
V. Nature of Community Work (please check one)
Beautification Project_______________
Clean and green project_____________
Staging community assemblies________
Religious program__________________
Parenthood/family planning program________________
Medical/dental service_________________
Nutrition/feeding program_________________
Drug Addiction Seminar Workshop_____________
Literacy Program__________________
Water and energy conservation project_______________
Disaster Awareness and Prevention Program____________
Healthy Lifestyles Program_______________
Sports and Recreation Program________________
 Other________________________________________________
_____________________________________________________

Survey by: Certified true and correct:

________________________________ ___________________________
Member Team:________________________ Barangay Chairman

Noted by:

______________________________ ________________________________
Team Leader NSTP-CWTS Instructor