Promoting Resiliency and a Climate-informed Gerona

PEOPLE’S SURVIVAL FUND (PSF)

FARM HOUSEHOLD SURVEY TOOL

IDENTIFICATION (Note: To be filled in by Researcher before field interview)
Questionnaire Number
Household Number

Barangay
Coordinates
CrFS Beneficiary  Yes  No

INTERVIEWER VISITS 1st Visit 2nd Visit Final Visit

 Date
 Interviewer’s Name
 Result

Codes:
1 Completed interview 3 Postponed
2 Incomplete interview 4 Refused

NOTES TO INTERVIEWER
 CrFS beneficiary refers to the family with CrFS graduates
 Interview the household head as possible
 ‘Household head’ refers to the main breadwinner in the household/family

INTRODUCTION
 Hello, good morning/afternoon! My name is ____________________. I am a RESEARCHER
and I am working with the Local Government Unit for the People’s Survival Fund Project.
 I am/we are here to gather some data about your household.
 This survey is being done by the LGU. The results of this survey will help the LGU in developing
the programs and activities for the early warning system in health, groundwater
study________________________.
 We are going to ask you some questions but we assure you that your answers will be treated
with utmost confidentiality.
 We can skip questions that you do not want to answer. However, we would very much
appreciate your full participation in this survey. You can also stop the interview at any time.
 The survey will take approximately ____ minutes to ___hour to complete.
 At this time, is there anything you want to know more about the survey? If none, may I begin the
interview?

CONSENT: (Check appropriate box)

Respondent AGREES to be interviewed: Respondent DOES NOT AGREE to be interviewed:

YES NO
 Indicate start time of interview below
 Proceed to next page and start interview  End. Thank respondent

START time of Interview: ________________

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SECTION A. Qualifying Question
What are the top 3 sources of HH livelihood? (multiple answers)
[ ] farming
[ ] vending/selling
A.1 [ ] employment
[ ] others, off-farm livelihood: please specify _________________________________________

SECTION B. Personal Information of Respondent

B.1 Name of Farmer
B.2 Sex of Respondent [ ] male [ ] female

B.3 Age of Respondent

Tenurial status [ ] Farm owner
[ ] Farm-owner cultivator
[ ] Tenant
[ ] Lessee
[ ] Farm worker

B.4 Member of a farmers organization/ [ ] Yes [ ] No

cooperative
B.5 Name of organization/cooperative
B.6 Agri-Fishheries trainings attended Training Sponsor

B.7 Support services received from LGU Provincial Govt DA RFO Others
B.7.1 Support services received as
individual

B.7.2 Support services received as part

of the organization

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SECTION C. Household Profile
Relation to Age Highest With Type of Disability Sources of Income
Name farmer (C.3) Sex Educ. Disability? (C.7) Primary Source of Paid or Unpaid/ Secondary Source Paid or Unpaid/
(C.1) respondent M/ F Attainment Y/N Income) Est. Monthly of Income Est. Monthly
(C.2) (C.4) (C.5) (C.6) (C.8) income (C.10) Income
(C.9) (C.11)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.

Notes:
If other family members live in other places, inquire if they contribute to the household income. If they do, include them in the listing above and indicate the amount contributed to the household income.
Use additional sheet if necessary for the household’s background composition.

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SECTION D. INCOME GENERATION & HOUSEHOLD ECONOMY

D.1 Farm location and crops planted

Croppin Possible
Farm Area g Cause of reason for
Farm Farm Crops Average Lowest Highest
size devoted season the low highest yield
No. location planted yield yield Yield
(sq.m.) to crops (1.6) yield (1.11)
(1.1) (1.2) (1.4) (1.7) (1.8) (1.10)
(1.3) (1.5) (1.9)
Wet Dry

D.2. Other Agri-Fisheries and Family Assets

Other Assets Detail (in terms of count, make, cost Estimated cost
(2.1) of acquisition (2.3)
(2.2)
Shelter

Farm machineries

Carabao
Cattle
Goat
Swine/ Hog
Poultry (chicken, duck)
Others (please specify)

Note: * - D – for draft purposes; C – for consumption and sale purposes

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D.3 During the last 10 to 20 years, please check applicable answer and indicate intensity of impact on corresponding columns.

Climate related Hazards When did this Describe event Injury or loss Crop Stage of Farm Affected Other Assets (could Impacts to the Other
that happened in Gerona happen? (i.e. flooding of life within planted Crop when it (refer to farm no be AF assets related Assets
(i.e. TC, flooding due to (recall the lasted for 2 days the when it hit hit and location) or in term of shelter) (partial, total
intense rains, drought/dry month and and up to waist household, if (3.5) (3.6) (3.7) affected by the damage,
spell or dry conditions, year this deep) any particular event unrecoverable)
pest epidemic, etc) happened) (3.3) (3.4) (3.8) (3.9)
(3.1) (3.2)

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D.4 Details on the water source and usage
Volume of water (proxy) (4.4)
Cropping Is the source
Number of
Source of Farm size Crops season # of Hours Type of sufficient?
Farm times in a
water (sq.m.) planted (4.3) when water Water (4.5)
No. cropping
(4.1) (4.2) is pumped Pump
Wet Dry season
(4.4.1) (4.4.3) Yes No
(4.4.2)

D.5 Production Capital

Source of production capital (please tick all that applies)
( ) own savings
[ ] Cooperative with interets (____) [ ] Bank with interest (_______)
[ ] Others_______ --- without interest [ ] Community Savings Group /Paluwagan wit interests__
[ ] Microfinance (with interest _____)
[ ] Others, specify: ______________

If loaned, how much

SECTION E. HEALTH, EXISTING WATER SOURCE AND WASH

D.1 Health
What are the 3 most common health problems in your household? (select 3 only)
[ ] Acute respiratory infection [ ] Pneumonia [ ] Cough and colds
[ ] Fever [ ] Diarrhea [ ] Dengue
D.1.1 [ ] Hypertension [ ] Tuberculosis [ ] Malnutrition
[ ] Skin diseases [ ] Arthritis [ ] Others, specify

In the past 6 months, did any of the household members get sick?
D.1.2
[ ] Yes [ ] No [ ] Don’t know
Did you seek treatment for this health problem?
D.1.3
[ ] Yes [ ] No [ ] Don’t know
If yes, where did you first seek treatment or advice for this health problem?
[ ] Private doctor [ ] Private pharmacy
D.1.4 [ ] Government Health Center [ ] Public/ government hospital
[ ] Private hospital/ clinic [ ] Traditional practitioners (i.e. manghihilot)
[ ] Self-medication [ ] Others, pls specify ______________
If No, why?
D.1.5
What public health facilities and personnel are available in your barangay? (multiple answers)
[ ] Barangay Health Center [ ] Barangay Health Workers
D.1.6 [ ] Barangay Nutrition Scholars [ ] Botika sa Barangay
[ ] Government Nurse [ ] Others, specify _________________

Did your household access any of these community health services in the last 6 months?
D.1.7
[ ] Yes [ ] No [ ] Can’t remember
Can you name any programs and/or services on health and nutrition in your barangay that you are
aware of? Which of these did you avail in the past 6 months?
List of Programs/ Services Availed (Y/N)
1.
D.1.8
2.
3.
4.
5.

D.2 HH Water Source and WASH

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Sources of Water Use
Piped and metered/ Monthly Bill
Other sources
- own hand pump/deep well
- communal or owned by
others
Volume of Water Used per Month
Water vessel used ________ (.ie. 4
drums a day
Water vessel used ________ (.ie. 4
drums a day

Seasonality of water availability of pumped water..

J F M A M J J A S O N D

sufficient throughout the year [ ] seasonal [ ] not sufficient throughout the year
If outside your residence, is the main source of water near your residence? [ ] Yes [ ] No
D.2.3

D.2.4 If No, how long does it take to fetch water?

[ ] 0 – 15 mins [ ] 15 – 30 min [ ] 31- 45 mins [ ] 46-60 mins [ ] more than 60 mins

Who usually fetch water in your HH?

[1] adult men
[2] adult women
[3] boy child
D.2.5
[4] girl child
[5] water vendors
[6] others, please specify: ___________________

END OF INTERVIEW. Ask respondent if they have clarifications, additions, etc. If none, thank the respondent.

END of Interview: _____________

_____________________________________ __________________________________
Name and signature of the researcher/Date Name and signature of the encoder/Date

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