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Did your family submit a status report during the previous round of survey, either through this app or to an LGU Representative?: SELECT YES NO

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FAMILY ID: FULL NAME OF FAMILY HEAD or PERSON INDICATED IN THE QUARANTINE PASS, IF ANY:* CITY / MUNICIPALITY:* SELECT BARANGAY:* SELECT ADDRESS:*

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Providing us with the exact location of your house will allow for the support to reach you faster. If you agree, please stand outside your house, turn the GPS /location function of your phone on, press the following button and wait for numbers to appear in the Longitude and latitude fields

Obtain house location

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LONGITUDE: LATITUDE:

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RELIGION:* SELECT CATHOLIC PROTESTANT IGLESIA DATING DAAN OTHER CHRISTIAN ISLAM NO RELIGION OTHERS PARISH CHURCH / MOSQUE / TEMPLE:*

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YOUR FAMILY ID:

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DOES YOUR FAMILY CURRENTLY ENCOUNTER THE FOLLOWING ISSUES (PLEASE CHECK ALL THAT APPLIES AND ANSWER THE ASSOCIATED QUESTION):

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SHORTAGE OF FOOD

Did your family receive any food pack since the beginning of the lock down?: SELECT YES NO When did you receive the food pack?:

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SHORTAGE OF MONEY

Did your family receive any Family Amelioration Fund?: SELECT YES NO How much and when did you receive Family Amelioration Fund?:

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LOST JOB DUE TO COVID-19

Since when?:

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LACK OF COOKING GAS

Since when?:

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NO ACCESS TO DRINKING WATER

Since when?:

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NO ACCESS TO TAP WATER

Since when?:

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NO ELECTRICITY

Since when?:

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NO PHONE SIGNAL

Since when?:

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SECURITY PROBLEM

Describe the security issue: Since when?:

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OTHER ISSUES

Describe the issues:

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YOUR FAMILY ID:

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DOES YOUR FAMILY CURRENTLY ENCOUNTER THE FOLLOWING ISSUES (PLEASE CHECK ALL THAT APPLIES AND ANSWER THE ASSOCIATED QUESTION):

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IS THERE A SENIOR CITIZEN IN THE FAMILY?

how many:

IS THERE A PWD IN THE FAMILY?

how many:

IS THERE A SPECIAL CHILD/PERSON IN THE FAMILY?

how many:

IS THERE A PREGNANT OR LACTATING MOTHER IN THE FAMILY?

how many:

ARE THERE CHILDREN BELOW 5 YEARS OLD IN THE FAMILY?

how many:

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IS THERE A SICK MEMBER IN THE FAMILY?

How many members of the family are sick?:

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Please fill-in the data for each of the sick member of the family:

Full Name: Age: Sex: SELECT MALE FEMALE

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Manifest any of these symptoms: dry cough, fever, tiredness, difficulty breathing SELECT YES NO

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Has a chronic disease (hypertension, TB, Asthma, Bronchitis, Diabetes, cancer,…) SELECT YES NO

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Encountered a COVID19 Positive person in the last 14 days? SELECT YES NO I DONT KNOW

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Arrived from ABROAD or another PROVINCE or CITY in the last 14 days? SELECT YES NO I DONT KNOW

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Point of origin of the person who arrived in the last 14 days?

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Need Health Assistance? SELECT YES NO

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ADD ANOTHER FAMILY MEMBER

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YOUR FAMILY ID IS:

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Please write down this ID and keep it properly. It will be required to submit a new status report during the next round of the survey.

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The information you have provided will now be submitted in order to help them direct the response to those most in need. Thank your participation.

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In case of an emergency you can obtain direct assistance through the following numbers:

TELEPHONE NUMBER:

Stay Safe!

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CLOSE THIS WINDOW

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