Questionnaire on Community Health Nursing

Name of the community/ barangay_________________________________

Location of the community________________________________________

Name of the community health nurse________________________________

Age_______ Sex____ Status_____ Highest Educational Attainment ______________

Number of years as CHN in the present Community_________________________

Number of years as CHN in other communities______________________________

Trainings Attended in relation to Community Health Nursing

Seminar / Workshop Date (year) Venue Sponsoring Agency

1. Size and Type of Community

Land area: _______ Geographic unit: barrio____ village______ barangay_____

Type of community: rural_____ urban_______ rurban(suburbs)________

Agricultural_______ industrial________ shanty town______

Informal settlers/squatters_________

Socio-economic class: Class I____ Class II_____ Class III_____ Class IV

Natural resources: forest_____ river____ lake_____ volcano______

sea_____ ocean_____ mountain_____ tourist spot_____

II. Demographic profile of the Community

Total Population________ Year when census was taken___________

Population density _____________ sex ratio (male to female) _____________

Age structure (percentage of the population)

0-1year old _________ Widow________ Separated__________

Single parent_________ Widower _______ Divorce___________

Married_________ Annulled________

Total number of families/household_________ Average family size________

Top three ethnic groups according to number or predominance in the community (like

Visayans, Tagalog, Ilokanos, Kapangpangans, Bicolanos, Aetas and etc….).

1. ______________________________________________________________

2. ______________________________________________________________

3. ______________________________________________________________

Top three predominant religions/religious groups/sectors, etc…)

1. ______________________________________________________________

2. ______________________________________________________________

3. ______________________________________________________________

III. Socio-economic Data

Top three main occupation/industries

1. _____________________________________________

2. _____________________________________________

3. ______________________________________________

Other sources of income or community livelihood programs

1._________________________________________________

2. _________________________________________________

Average Family Income: check the bracket and indicate percentage of the population

with corresponding monthly family income.

Below 5,000.00 php __________________________

Above 5,000.00-10,000.00 php. __________________________

Above 10,000.00-15,000.00 php __________________________

Above 15,000.00-20,000.00 php ___________________________

Above 20,000.00-30,000.00 php ____________________________

Unemployment rate___________________________

Percentage of population below poverty level_______________________

Percentage of population who completed;

1. Elementary ________________ 4. Graduate school _____________

2. High school_________________ 5. Never attended school ___________

3. College ___________________

IV. Epidemiologic Profile of the Community

Top 5 Causes of

MORTALITY

Number of Cases Actions Taken or Suggested Actions/Solutions

Top 5 Causes of

MORBIDITY

Number of Cases Actions Taken or Suggested

Actions/Solutions

V. Environmental Health Facilities

Water Supply

Source of supply ____________________

Type of water supply: owned (pose, jetmatic) __________ Bought _____

Shared _________ Others, specify _________

Quality of water________________________________

Waste disposal system: Check the appropriate and indicate the percentage.

Flush _________ Wrap and throw________ Water sealed__________

Pit privy_______ Others, Specify_________________

Refuse/garbage disposal: Check the appropriate answer and indicate the percentage.

Collected___________ Open dumping_____________

Waste segregation_________ Burning_______________

Feeding leftover to animals_________ Burying_________________

Balot –tapoin in the river/sewer ____________ Others, specify ___________

Housing: check the answer and indicate the percentage.

Wood ____________ Concrete _________________

Makeshift_______________ Mixed (wood & concrete) ________________

Questionnaire for the Community Health Nurse

As the Community health Nurse, Please answer the questions briefly and

candidly as possible.

1. What are some difficulties/problems that you encountered in the performance

of your roles/duties?

2. What are your suggestions to improve your performance and your workplace?

3. Politely request the Community Health Nurse to fill up the checklist below by checking the box which indicates his/her corresponding roles and functioning as a CHN. Attach this form questionnaire on Community Health Nursing.

Name of Nurse: _______________Name of Student Nurse:______________________

Designated Position: _________Place of Assignment__________________________

Date of Interview: ______________________

Roles CN HC CB ED CL AV MG RSProvide knowledge, skills and attitude.Bring together strengths and weaknesses.Focus on health teachings.Key tasks include listening and providing information.Providing care skills.Promote self-care and self-determination.Predict future phenomenon and modify interventionsOversees the training of midwives.Prepare documents and reports.Undertakes demographic and epidemiological surveys.Refers cases to other members of the health care team.

Legend: CN=counsellor, HC=home care, CB=collaborator, ED=educator, CI=clinicians, AV=advocate, MG=manager, RS=researcher