Date_______________________________ Province/City___________________________

Interviewer__________________________ Municipality___________________________
Church_____________________________ Barangay______________________________

PHILIPPINE COMMUNITY AND CHURCH BASED

MONITORING SYSTEM FOR TRACKING INNOVATION

Name of Household_______________________________________________Age_________ Sex_________ Status: Married _________Single _________Widowed _________ Separated _________
Occupation _____________________________________________Wage ___________ / Daily_____________ / Weekly Status of Employment: Self Employed ___________ Employed___________
Name of Spouse _______________________________________ Age ________ Sex ________ Occupation _________________ No. of Children: Total ________ Male ________Female _________
Address ____________________________________________________________________________________________ Other Dependents No.: Total ________ Male ________Female _________

Fill-up Directions
1. Check the column that applies to your answer: (y=yes); (n=no); (na= not applicable); (dk=don't know).
2. Submit accomplished form to MBI-1 Barangay Monitoring Team (BMT) Leader submitted to Church Monitoring Team every semester for processing.SM1: January SM2: June

Note: This form shall be used for three (3) years.

2 0 1 0 2 0 1 1 2 0 1 2
BASIC NEEDS INDICATORS S 1 S 2 S 1 S 2 S 1 S 2
y n na d y n na d y n na d y n na d y n na d y n na dk
k k k k k
A.SURVIVAL 1.Newborns with birth weight of at least
1. Food and Nutrition 2.5 kgs,
2.No severely and moderately underweight
children under 5 years old
3.Pregnant and lactating mothers provided
with iron and iodine supplements
4. Infants exclusively breastfed for at least
4 months
2. Health 5. Deliveries attended by trained personnel
6. 0-1 year old infants fully immunized
7. Pregnant women given maternal care
8. Not more
9. No deaths in the family due to
preventable causes within one year
10. Couples with access to family planning
11. Couples practicing family planning in
the last 6 months
12. Family members availing of health
care services
3. Water and Sanitation 13. Family with access to potable water
(faucet/deep well within 250 meters (10
min. walk)
14. Family with sanitary toilet (water-
sealed, flush type)
4. Clothing 15. Family members with basic clothing
(at least 3 sets of external and internal
clothing)
Philippine Business Advisory Council Assemblies of God MBI-1
 2 0 1 0 2 0 1 1 2 0 1 2
BASIC NEEDS INDICATORS S 1 S 2 S 1 S 2 S 1 S 2
y n na d y n na d y n na d y n na d y n na dk y n na dk
k k k k
16. Housing owned
B.SECURITY
5. Shelter 17. Housing durable for at least 5 years
6. Peace and Order / 18. Family members safe from crimes
Public Safety against person (murder, rape, abuse,
physical injury)
19. Family members safe from crimes
against poverty(robbery, theft, and other
crimes)
20. Family members safe from natural
disaster (landslide, flood)
21. Immediate response of police or
barangay tanod in case of emergencies
7. Income and 22. Head of Family employed
Livelihood 23. Other members of the family 15 years
and above employed
24. Family with income sufficient for daily
existence
25. All children in school age are in school
C. ENABLING 26. Children 6-12 years old in elementary
8. Basic Education and school
Literacy 27.Children 13-16 years old in high school
28. Children 16-20 above are in college
9. People’s 29. Family members involved in at least
Participation in legitimate people’s organization / assn. for
Community community development
Development 30.Family members able to vote at
elections
10. Family Care / 31. No children below 15 years old
Psychosocial engaged in hazardous occupation
32. No incidence of domestic violence
33. No children below 7 yrs. old left
unattended
11. Debt from 34. Up to present
Micro financing 35. Before but stopped
12. Assignment of 36. Husband
Household Chore 37.Children
13. Saving Ability 38. Able to have extra in case of
emergency
14. Improvements in 39. Able to eat 3 times a day
Standard of Living 40. Able to go to mall, eat out and buy new
clothes

Philippine Business Advisory Council Assemblies of God MBI-1

Philippine Business Advisory Council Assemblies of God MBI-1