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Household Information Survey
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
What is your name?
Please provide your first name.
2
What is your middle name?
Please provide your middle name, if any.
3
What is your last name?
Please provide your last name.
4
What is your gender?
Please select your gender.
Male
Female
Other
5
What is your contact number?
Please provide a contact number where you can be reached.
6
What is your occupation?
Please specify your current occupation.
7
What is your school attainment level?
Please select the highest level of education you have completed.
Primary School
High School
College
Postgraduate
8
How many additional household members are there?
Please enter the total number of additional household members excluding yourself.
9
What is your address?
Please enter your full address including purok and city.
10
Please rate the satisfaction level of this survey.
Rate your satisfaction level from 1 to 10 (1 being the lowest and 10 being the highest).
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