NEEDS ASSESSMENT SURVEY FORM
Complete Name
*
First Name
Middle Name
Last Name
Gender
Male
Female
Age
Civil Status
Single
Married
Widowed
Separated
Spouse Name
First Name
Middle Name
Last Name
Spouse Age
How many children do you have?
Child #1
Complete Name
Gender
Age
Child #2
Complete Name
Gender
Age
Child #3
Complete Name
Gender
Age
Child #4
Complete Name
Gender
Age
Child #5
Complete Name
Gender
Age
Child #6
Complete Name
Gender
Age
Child #7
Complete Name
Gender
Age
Child #8
Complete Name
Gender
Age
Child #9
Complete Name
Gender
Age
Child #10
Complete Name
Gender
Age
Spouse Occupation
Farmer
Miner
Driver
Fisherman
House Wife
Businessman
Construction Worker
Government Employee
Other
Status of Employment
Employed
Self-employed
Unemployed
Occupation
Farmer
Miner
Driver
Fisherman
Government Employee
Construction Worker
Businessman
Other
Monthly Income
P 0.00 – P 10,000
P 10,001 – P 20,000
P 20,001 – P 30,000
P 30,001 – P 40,000
P 40,001 – P 50,000
P 50,001 – P 60,000
P 60,001 – P 70,000
P 70,001 – P 80,000
P 80,001 – P 90,000
P 90,001 – P 100,000
P 100,001 – P 150,000
P 150, 001 – Above
Educational Attainment
Elementary Level
Elementary Graduate
High School Level
High School Graduate
College Level
College Graduate
Vocational Graduate
Religious Affiliation
Please Select
Roman Catholic
Iglesia ni Cristo
Evangelicals (PCEC)
Protestant (NCCP)
Aglipayan
Seventh-day Adventist
Bible Baptist Church
United Church of Christ in the Philippines
Jehovah's Witnesses
Islam
Not Available on the List
Other Religous Affiliation
Name of Religious leader
First Name
Last Name
What is the location of your birthplace?
What languages or dialects are commonly spoken in the area?
Are you currently affiliated with any organization or group?
Yes
No
Name of the organization/group
Essential Data to Collect from Barangay Residents
Forms of livelihood in the Barangay
Please Select
Agriculture and Farming
Fishing and Aquaculture
Livestock Rearing
Small-Scale Business and Entrepreneurship
Retail and Trade
Tourism and Hospitality Industry
Manufacturing and Cottage Industries
Services Sector (e.g., transportation, healthcare, education)
Informal Economy (e.g., street vendors, home-based workers)
Remittances from Overseas Filipino Workers (OFWs)
Not Available on the List
Other Forms of livelihood in the Barangay
Would you like to learn TESDA skills training?
Yes
No
List of TESDA Courses
Please Select
Digital Animation Courses
Automotive Courses
Automotive Servicing NC II
Business and Management Courses
Driving Courses
Hotel, Restaurant, Culinary and Food Management Courses
Advance Eskrima Language Courses
Agriculture and Fishery Courses
Aircraft and Aviation Courses
Cosmetology and Beauty Care Courses
Electronics and Electrical Courses
Caregiver Courses
Computer Related and Software Development Courses
Building Construction and Welding Courses
Call Center and Contact Center Services Courses
Dental Technology Courses
Entrepreneurship and Management Courses
Health Care and Medical Related Courses
Heavy Equipment Operation Courses
Household Services and Housekeeping Courses
Industrial and Manufacturing Courses
Refrigeration and Air Conditioning
Trainer Qualification Courses
Do you have a driver's license?
Yes
No
Would you like us to help you get your driver's license?
Yes
No
Effects of natural calamities in your Barangay
Please Select
Destruction of Buildings and Properties
Harm to Crops and Farming
People Losing Homes and Having to Move
People Getting Hurt and Suffering
Needing Help Fast
Jobs and Businesses Going Away
Money Problems and Less Stuff Made
Things Costing More
People Dying and Families Hurting
Hurt Environment and Danger to People
Are there any mining groups operating within the barangay?
Yes
No
Name of the Mining Organization
What is the state of infrastructure, particularly roads and bridges, in the area?
Please Select
Good condition
Needs fixing
Being built or improved
Gets damaged easily
Needs more money for building
Okay but needs better connections and safety
Not enough money for upkeep
Often has too much traffic
Needs planning for the future
Helps people with few problems
What are the primary sources of water in the area?
Please Select
Rivers and streams
Lakes
Groundwater (wells and aquifers)
Rainwater harvesting
Reservoirs and dams
Springs
Water treatment plants
Desalination plants (in coastal areas)
Irrigation canals
Community water systems
What are the prevalent diseases or health concerns in the community?
Please Select
Dengue fever
Tuberculosis (TB)
Hypertension (High blood pressure)
Diabetes
Respiratory infections
Diarrheal diseases
Malnutrition
Dengue Hemorrhagic Fever (DHF)
Pneumonia
Typhoid fever
Hepatitis
Measles
Malaria
Cholera
Leptospirosis
HIV/AIDS
Parasitic infections (e.g., amoebiasis)
Skin diseases (e.g., scabies)
Dengue Shock Syndrome (DSS)
Maternal and child health issues (e.g., maternal mortality, infant mortality)
Not available on the list
Other prevalent diseases or health concerns in the community.
What type of electricity is used in your barangay?
Please Select
Solar power
Hydroelectric power
Diesel or gasoline generators
Electricity from big power lines
What economic opportunities and employment options are available in our barangay?
Please Select
Opening small stores or food shops
Growing crops like rice and vegetables
Raising animals like pigs and chickens
Making things like baskets and pottery
Fishing in nearby rivers or the ocean
Working for the barangay or government
Helping with community projects or tourism
Working at schools or helping teachers
Building things or fixing roads
Helping tourists or selling souvenirs
What are the most significant social issues affecting our barangay?
Please Select
Poverty and income inequality
Lack of access to education and educational resources
Unemployment and underemployment
Substance abuse and addiction
Domestic violence and abuse
Child labor and exploitation
Gender inequality and discrimination
Lack of affordable housing and homelessness
Teenage pregnancy and reproductive health issues
Elderly neglect and social isolation
Mental health issues and lack of support services
Crime and public safety concerns
Access to clean water and sanitation facilities
Migration and displacement of residents
Lack of community cohesion and social support networks
Are you satisfied with the availability and quality of healthcare services in our barangay?
Yes
No
Do you feel safe in our barangay in terms of crime and public safety?
Yes
No
How would you are educational facilities and resources for residents in our barangay?
1
2
3
4
5
How would you rate the condition of roads and public spaces in our barangay?
1
2
3
4
5
How would you rate the overall cleanliness and waste management in our barangay?
1
2
3
4
5
How effectively does the barangay government address the needs and concerns of residents?
1
2
3
4
5
How would you rate the emergency response services and disaster preparedness measures in your barangay?
1
2
3
4
5
Which government agencies would you like to see bring their services to your barangay?
Please Select
Department of Education (DepEd)
Department of Health (DOH)
Land Transportation Office (LTO)
Philhealth
Local Civil Registrar (LCR)
Department of Agriculture (DA)
Department of Transportation (DOTr)
Department of Public Works and Highways (DPWH)
Department of Social Welfare and Development (DSWD)
Department of Environment and Natural Resources (DENR)
Department of Trade and Industry (DTI)
Department of Labor and Employment (DOLE)
Department of Information and Communications Technology (DICT)
Commission on Higher Education (CHED)
Civil Service Commission (CSC)
Philippine Statistics Authority (PSA)
National Commission on Indigenous Peoples (NCIP)
Technical Education And Skills Development Authority (Tesda)
Not available on the list
What government services would you like to bring to your barangay to improve the quality of life for residents?
Please Select
INFRASTRUCTURES
EDUCATION
HEALTH & SANITATION
SOCIAL SERVICES
Health
Please Select
Medical Caravan
Dental Caran
Libreng Tuli
Maternal and Child Health Services
Disease Prevention and Control
Health Education and Promotion
Mental Health Services
Water, Sanitation, and Hygiene (WASH)
Infrastructures
Please Select
Road Construction and Improvement
Bridges
Water Supply Systems
Sanitation Facilities
Waste Management Systems
Internet and Computer Labs
Schools
Libraries
Electricity Supply
Street Lighting
Marketplaces
Agricultural Infrastructure
Emergency Shelters
Education
Please Select
Daycare Centers
Preschools
Alternative Learning Systems (ALS)
E-Learning Platforms
Vocational Training Centers
School Supplies and Materials
School Feeding Programs
Social Services
Please Select
Pantawid Pamilyang Pilipino Program (4Ps)
Livelihood Assistance Programs
Feeding Programs
Job Fair
Do the police regularly visit your barangay?
Yes
No
How often do the police visit?
Everyday
Once a week
Twice a week
Thrice a week
Do the army regularly visit your barangay?
Yes
No
How often do the army visit?
Everyday
Once a week
Twice a week
Thrice a week
Do elected officials visit your barangay?
Yes
No
How often do the elected officials visit?
Everyday
Once a week
Twice a week
Thrice a week
Please list down any other issues or concerns that you have in mind.
Submit
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