Pre-Disaster Data v4.3-2017: Form 1
Diocese of
*
Please Select
Parañaque
Pagadian
Surigao
Palo
Cebu
Davao
Iloilo
Dumaguete
Manila
Parish:
Enumerator
*
Time / Date
-
Month
-
Day
Year
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1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Family Head Name
*
First Name
Last Name
Family ID
*
Contact Number
Address
House Number
Street
Sitio / Purok
Subdivision / Brgy
City / Municipality
Province
Parish
Zone
Chapel
BEC
YEARS OF STAY IN CURRENT ADDRESS
Years
Months
Place of Origin
House Data
Ownership
Owned
Mortgaged
Rented
Transient
Tenant
Informal
Other
Type
Residential
Commercial
Industrial
Office
Resort
Other
Construction Material
Light (Nipa, Sawali)
Wood, Nipa
Wood, Concrete, GI-Sheets
Concrete, GI-Sheets, Others
OTHER DETAILS
Floor
1 Floor
2 Floors
3 Floors
Higher then 3
Year Constructed
Approximate Value
Content Value
Average Family Income Per Month
1,000 - 5,000
5,001 - 10,000
10,001 - 15,000
15,001 - 20,000
20,001 - 25,000
25,001 - 30,000
30,001 - 35,000
35,001 - 40,000
40,001 - 45,000
45,001 - 50,000
50,001 - Above
Family Had Personal Transport Vehicle / Vehicle for Evacuation
Rubber Boats/Boats/ Pumpboats
Trucks/Buses
Car/Jeep/SUV
Motor Vehicle/Habal-habal
Tricycle
Bicycle
Padyak
Horse/Carabao/cow
None
Other
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LIFE LINES
Food Source
Local Market
Local Grocery
Household Garden / Farm
Household Stock
Water Source
Water District
Village Suppply
Household Deep Well
Delivery
Electricity Source
Local Power Supply
Household Generator
Solar, Wind, Etc.
Communication
Landline
Mobile
Radio (UHF/VHF/HF)
Internet
GPS Coordinates
Longitude
Latitude
Elevation
TOTAL OCCUPANTS
Day Time
Night Time
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HAZARDS WITH MOST DAMAGE (DETAILS, DATE)
Wind
Date for Wind Hazard
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Month
-
Day
Year
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Surge
Date for Surge Hazard
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Month
-
Day
Year
Date Picker Icon
Flood
Date for Flood
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Month
-
Day
Year
Date Picker Icon
Quake
Date for Quake Hazard
-
Month
-
Day
Year
Date Picker Icon
Fire
Date for Fire Hazard
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Month
-
Day
Year
Date Picker Icon
Landslide
Date for Landslide
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Month
-
Day
Year
Date Picker Icon
Armed Conflict
Date for Armed Conflict
-
Month
-
Day
Year
Date Picker Icon
WHERE DO YOU EVACUATE?
Neighbor
Relative
Curch
School
Public Area
None
Other
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INFORMATION ACCESS
Sources (IN)
Government (Local Government Unit, Barangay, etc.)
Church
Radio/TV/TV/Print
Social Media
Do you have comm with
Government (Local Government Unit, Barangay, etc.)
Church
Emergency Units
Media Stations
OTHER LIFE LINES
(WHAT IS THE NEAREST STATION)
Medical (Hospital, Clinic, etc.)
Fire
Security (PNP, AFP, Barangay Tanod, etc.)
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