Senior Citizen Survey Form (Long)

Republic of the Philippines
Province of Eastern Samar

MUNICIPALITY OF BALANGIGA
2602 - _______
__________________________ OSCA Brgy. Code
(Barangay)
SENIOR CITIZEN SURVEY FORM

(Please answer appropriately and legibly)
NAME: ________________________________________________________________________
(Last Name) (First Name) (Middle Name)
ADDRESS: _____________________________________________________________________
(House No., Street Name, Barangay, Municipality)
DATE OF BIRTH: __________________________________________ SEX: __________

(Year) (Month) (Day)
PLACE OF BIRTH: _______________________________________________________________
CIVIL STATUS: q Single q Married q Widow/Widower q Separated
RELIGION: q Roman Catholic q Iglesia ni Cristo q Protestant q Islam

Others, Pls. Specify __________________________
I.D. NUMBER: OSCA ____________________ GSIS ________________

TIN ____________________ SSS ________________
PhilHealth _________________
FAMILY COMPOSITION:
Name Relationship Age Civil Status Occupation/Income
EDUCATIONAL ATTAINMENT:
q Elementary q Elem. Grad. q High School q HS Grad. q College Level q College Grad. q Not Attended Any School
SOURCE OF INCOME AND ASSISTANCE:

q Own Earnings, salaries/wages q Spouse's Salary q Rental/sharecrops q Own Pension
q Insurance q Savings q Stocks/Dividends q Spouse's pension
q Dependents on children/relatives q Livestock/orchards q others, specify __________________________
ASSETS AND PROPERTIES:

q House q Farmland q Commercial Bldg. q House and Lot q Fishpond/Resorts q others, specify __________
MONTHLY INCOME: (in Philippine Peso)
q 10,000 & above q 9,000 – 9,999 q 8,000 – 8,999 q 7,000 – 7,999 q 6,000 – 6,999 q 5,000 – 5,999
q 4,000 – 4,999 q 3,000 – 3,999 q 2,000 – 2,999 q 1,000 – 1,999 q others, specify ______________
LIVING/RESIDING WITH: (Check all applicable)

q Alone q Children q Grandchildren q Spouse q House helps q Care Institutions
q Friends q Relatives q Common Law Spouse
AREAS OF SPECIALIZATION: (Check all applicable)
q Medical q Teaching q Legal Services q Dental q Counsel q Engineering
q Vocational q Arts q Evangelization q Cooking q Farming q Fishing
q others, specify ___________________
INVOLVEMENT IN COMMUNITY ACTIVITIES: (Check all applicable)

q Medical q Dental q Religious q Community Beautification
q Legal Services q Sponsorship q Counselling/Referral q Neighborhood Support Services
q Friendly Visits q Resource Volunteer q Community/Org. Leader q others, specify __________
PROBLEMS/NEEDS COMMONLY ENCOUNTERED: (Check all applicable)

a. Economic
q Lack of income/Resources q Loss of income/Resources q Skills/Capability training: (specify) ___________
q Livelihood opportunities: (specify) ____________ q others, specify ___________________________
b. Social/Emotional
q Feeling of neglect & rejection q Feeling of helplessness & worthlessness q Inadequate leisure/recreational activities
q Feeling of loneliness isolation q Senior Citizen friendly environment q others, specify ________________
c. Health
q High cost medicines q Lack of medical professionals q Lack/No access to sanitation
q Lack/No health insurance q Inadequate health services q Lack of hospital/Medical facilities
q Health problems/Ailments: specify _____________________ q others, specify ____________________________
d. Housing
q Living in squatters area q Lost privacy q High cost rent q Overcrowding in the family home
q No permanent housing q Longing for independent living/quite atmosphere q others, specify _____________
e. Community Service
q Desire to participate q Skills/Resources to share q others, specify ___________________________
f. Identify Other Specific Needs
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Contact Person in case of emergency: ___________________________ Contact #: _______________
Print Name and Signature of Senior Citizen Print Name and Signature of Interviewer
Date of Interview: ______________________

Senior Citizen Survey Form (Long)

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Senior Citizen Survey Form (Long)

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Republic of the Philippines

Province of Eastern Samar

SENIOR CITIZEN SURVEY FORM

DATE OF BIRTH: ________________________________ SEX:

PLACE OF BIRTH: _______________________________________________________________

CIVIL STATUS: q Single q Married q Widow/Widower q Separated

RELIGION: q Roman Catholic q Iglesia ni Cristo q Protestant q Islam

I.D. NUMBER: OSCA ____ GSIS

SOURCE OF INCOME AND ASSISTANCE:

ASSETS AND PROPERTIES:

LIVING/RESIDING WITH: (Check all applicable)

INVOLVEMENT IN COMMUNITY ACTIVITIES: (Check all applicable)

PROBLEMS/NEEDS COMMONLY ENCOUNTERED: (Check all applicable)

Contact Person in case of emergency: _____________ Contact #: _

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