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Questionnaire On Community Health Nursing

This document contains a questionnaire to collect data on community health and demographics in a specific barangay or village. It requests information on the size and type of community; demographic profile including population, age structure, families, ethnic and religious groups; socioeconomic data like occupations, income, education levels; epidemiological profile of top causes of mortality and morbidity; and environmental health facilities regarding water, waste disposal, housing and more. The questionnaire aims to gather comprehensive baseline data on the community to inform community health nursing.

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Darling Tocaldo Donio-Timba
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52 views4 pages

Questionnaire On Community Health Nursing

This document contains a questionnaire to collect data on community health and demographics in a specific barangay or village. It requests information on the size and type of community; demographic profile including population, age structure, families, ethnic and religious groups; socioeconomic data like occupations, income, education levels; epidemiological profile of top causes of mortality and morbidity; and environmental health facilities regarding water, waste disposal, housing and more. The questionnaire aims to gather comprehensive baseline data on the community to inform community health nursing.

Uploaded by

Darling Tocaldo Donio-Timba
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Questionnaire on Community Health Nursing

Name of the community/ barangay_________________________________


Location of the community________________________________________
1.

Size and Type of Community

Land area: _______

Geographic unit: barrio____ village______ barangay_____

Type of community:

rural_____

urban_______ rurban(suburbs)________

Agricultural_______ industrial________ shanty town______


Informal settlers/squatters_________
Socio-economic class:

Class I____

Natural resources:

forest_____ river____ lake_____ volcano______


sea_____

Class II_____ Class III_____ Class IV

ocean_____ mountain_____ tourist spot_____

II. Demographic profile of the Community


Total Population________

Year when census was taken___________

Population density _____________

sex ratio (male to female) _____________

Age structure (percentage of the population)


0-1year old _________

Widow________

Separated__________

Single parent_________

Widower _______

Divorce___________

Married_________

Annulled________

Total number of families/household_________ Average family size________

Top three ethnic groups according to number or predominance in the community (like
Visayans, Tagalog, Ilokanos, Kapangpangans, Bicolanos, Aetas and etc.).
1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________

Top three predominant religions/religious groups/sectors, etc)


1. ______________________________________________________________
2. ______________________________________________________________
3. ______________________________________________________________

III. Socio-economic Data


Top three main occupation/industries
1. _____________________________________________
2. _____________________________________________
3. ______________________________________________
Other sources of income or community livelihood programs
1._________________________________________________
2. _________________________________________________
Average Family Income: check the bracket and indicate percentage of the population
with corresponding monthly family income.
Below 5,000.00 php

__________________________

Above 5,000.00-10,000.00 php.

__________________________

Above 10,000.00-15,000.00 php

__________________________

Above 15,000.00-20,000.00 php ___________________________


Above 20,000.00-30,000.00 php ____________________________

Unemployment rate___________________________
Percentage of population below poverty level_______________________

Percentage of population who completed;


1. Elementary ________________
2. High school_________________
3. College ___________________

4. Graduate school _____________


5. Never attended school ___________

IV. Epidemiologic Profile of the Community

Top 5 Causes of

Number of Cases

Actions Taken or Suggested Actions/Solutions

MORTALITY

Top 5 Causes of
MORBIDITY

Number of Cases

Actions Taken or Suggested


Actions/Solutions

V. Environmental Health Facilities


Water Supply
Source of supply ____________________
Type of water supply: owned (pose, jetmatic) __________ Bought _____
Shared _________ Others, specify _________
Quality of water________________________________
Waste disposal system: Check the appropriate and indicate the percentage.
Flush _________ Wrap and throw________ Water sealed__________
Pit privy_______

Others, Specify_________________

Refuse/garbage disposal: Check the appropriate answer and indicate the percentage.
Collected___________

Open dumping_____________

Waste segregation_________

Burning_______________

Feeding leftover to animals_________

Burying_________________

Balot tapoin in the river/sewer ____________ Others, specify ___________

Housing: check the answer and indicate the percentage.


Wood ____________

Concrete _________________

Makeshift_______________ Mixed (wood & concrete) ________________

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