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Household Information Survey

Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.

Secured
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.
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.
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).