ECONOMIC SURVEY FORM

A. Characteristic of Household
Occupation
MARITAL POSITION IN THE FAMILY EDUCATIONAL Monthly/Daily
NAME AGE GENDER (Contractual/Regular of
STATUS (Head or Member) ATTAINMENT Income (php)
Permanent)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

B. Income, Expenditures and Savings

Primary Source of Income

(Check if Yes) Amount B.1. What is the total income of the Household:_____________________________
Wage/ Salary (Private/Government)

Trading (Pagpamaligya)
B.2. What is the estimated annual income of the household: ________________________
Rental Income (Naay gipaabangan i.e Balay, Taxi,
Sikad etc.) B.3. How do you consider your family
Agriculture (Copra or Poultry)
( ) Rich
Pension
( ) Middle Class
NGO Aid
( ) Poor
Government Poverty Aid (4p’s) (Please Specify)
( ) Very Poor
B.4. Subsistence Production: Naa bay tinanum or gibuhi nga gina-gamit pang konsumo

(Check if Monetary Value(if

Production Quantity
Yes) Available)
Vegetable
Poultry:
Eggs
Meat
Others: Please Specify

B.5. EXPENDITURES

EXPENDITURE MONTHLY ANNUAL

NECESSITIES
Food and Drinks
Electricity
Water
Health Care/Medical Care
Utilities
Housing
Transportation
Special Expenditures
Loan
Savings
FOR CHILDRENS EXPENDITURES (CHILD CARE)
Clothing
Education
Others (Please Specify)

B.6. SAVINGS: How and where do I invest my Savings?

Check if
Investment Corresponding Amount Interest Rate if present
Yes
Deposit in Bank
I buy gold
I buy immovable properties
If Others specify:
C. Education: If the respondent have children

Do all your children go to school? __________________________________________

School Attending (Emphasize if Private Other Expenses (Project, School Supplies,

Name of Children Grade/Year In Tuition
or Public) PTA etc)

D. HEALTH

Anyone from the household who have chronic/permanent health problem?___________________________________________

How Many?_________________________________________

Money Spend for Regular Check-ups:__________________________________________________

Medicine Maintenance: ____________________________________

Which Facility do you visit? (Private/Public):________________________________________________

E. Social Securities Do household members have:

( ) PhilHealth
( ) SSS
( ) GSIS
( ) Others; Please Specify