8/12/2019 Community Health Survey Form

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COMMUNITY HEALTH SURVEY FORM

Head of the Family:_____________________________________ House No.:____ Date Assessed:_______

Family Member Relationto Head Sex Age

MaritalStatus

EducationalAttainment Occupation

MonthlyIncomeNo. Name

CHILDRENS IMMUNIZATION No. NAME AGE SEX BCG DPT OPV HEPA B MEASLES

1. Type of Family : [ ] Nuclear [ ] Extended [ ] others, specify: ____________2. Home:

Ownership: [ ] Owned [ ] Rented [ ] others, specify: ____________Construction materials used:

[ ] Wood [ ] Mixed [ ] Concrete[ ] others, specify: ___________

Numbers of rooms used for sleeping: _______Lighting Facilities: [ ] Electricity [ ] Kerosene [ ] others, specify: ____________General Surroundings: [ ] Clean [ ] Dirty

3. Water Supply:

Source: [ ] Artesian well [ ] Deep well [ ] MAWASA [ ] others, specify: ____________Storage of Drinking Water: [ ] Covered [ ] Uncovered [ ] Refrigerated [ ] others, specify:______Sanitary Condition: ____________________

Kitchen:Cooking Facility: [ ] Electric Stove [ ] Gas Stove [ ] Firewood/CharcoalSanitary Condition: ______________Drainage Facility: [ ] Open [ ] Blind [ ] None

4. Domestic AnimalsKIND NUMBER WHERE KEPT

5. Pest / Insect:[ ] Mosquito [ ] Lizards [ ] Flies [ ] others, specify:_____

8/12/2019 Community Health Survey Form

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