FAMILY PROFILING FORM

Barangay: 9 Primary Care Provider: RHU BALAYAN

Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 1 year Mobile Number or Email Address (optional):
Complete Address: Plaza Burgos, Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) Blood Type *Marital Status (if PWD, specify) Attainment Occupation Number Religion Membership

Mendoza, Mark Anthony Credito Head Male 27 9/14/1992 CL-MF None Tricycle Driver Roman Catholic
Soreta, Rossete Alcomendas Wife Female 26 11/9/1992 CL-MF Elem. Grad. None 0955-384-5593 Roman Catholic
Mendoza, Princess Tonette Soreta Daughter Female 8 4/24/2011 S Grade 2 Roman Catholic
Mendoza, Saint Anthony Soreta Son Male 5 11/1/2013 S Roman Catholic
Mendoza, Alyana Soreta Daughter Female 1 5/1/2018 S Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specify) ____________________
b. Type of Construction Material: / Light Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts) Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS: Age is conflict with the date of birth.

House Connection)
 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DR. LAYLO
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 30 years Mobile Number or Email Address (optional):
Complete Address: Plaza Burgos, Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact
Family Position (Male, Female) Age (mm/dd/yyyy) Blood Type *Marital Status (if PWD, specify) Attainment Occupation Number Religion

Codizal, Eufronio Bagano Head Male 76 8/31/1943 O CL-MF O Elem. Grad. None Roman Catholic
Dela Cruz, Vilma Castor Wife Female 45 2/24/1973 A CL-MF A Elem. Grad. None 0936-136-1211 Roman Catholic
Dela Cruz, Robi Castor Grandson Male 7 7/25/2012 S Grade 1 Student Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specify) ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts) Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS:
vider: DR. LAYLO

**NHIP
Membership

SC

em or Individual House Connection)

Garbage Collection
 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 1 year Mobile Number or Email Address (optional):
Complete Address: Plaza Burgos, Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion

Ramirez, Jomer Gardian Head Male 23 12/28/1995 CL-MF College Grad. Chef Roman Catholic
Bason, Joan Soreta Wife Female 16 9/12/2003 CL-MF Grade 6 None 0905-904-1018 Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specify) ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts) Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type Sanitary unsanitary / None

REMARKS: Age is conflict with the date of birth.

 **NHIP
Membership

member

em or Individual House Connection)

Garbage Collection
 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DON MANUEL LOPEZ HOSPITAL/ DR. LAYLO
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 14 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9, Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Mendoza, Lolita Dela Luna Head Female 72 10/24/1947 W None None 0916-937-9445 Roman Catholic Senior/4ps
Mendoza, Geronimo Dela Luna Son Male 48 4/20/1971 Elem. Grad. None Roman Catholic
Mendoza, Emerson Delioro Grandson Male 14 12/7/2004 ALS None

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned / Rented Others (specify) ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts) Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type Sanitary unsanitary / None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 15 years Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Dalida, Norwil Rodriguez Head Male 41 10/19/978 CL-MF HS Grad. Mason Roman Catholic member-indirect
Cabras, Lea Reyes Wife Female 44 3/9/1975 CL-MF None Roman Catholic
Dalida, Jaira Mae Cabras Daughter Female 17 11/19/2001 S HS Grad. Roman Catholic 1-D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specify) ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts) / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 6 years Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) Blood Type *Marital Status (if PWD, specify) Attainment Occupation Number Religion Membership

Bartolo, Richard Veroya Head Male 37 11/1/1982 CL-MF Elem. Grad. Carpenter 0975-726-7404 Roman Catholic None
Quiambao, Shena Lopez LIP Female 35 1/22/1984 CL-MF Elem. Grad. Midwife Roman Catholic member-INHTS
Quiambao, Suzzane Lopez Daughter Female 14 1/14/2005 S Grade 9 Student Roman Catholic 1-D
Quiambao, Edrian Lopez Son Male 13 4/2/2006 S Grade 8 Student Roman Catholic 1-D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned Rented / Others (specify) Tenant/ Sharing
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts) / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container / Covered uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type Sanitary unsanitary / None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 6 years Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Romero, Domingo Rosas Head Male 58 3/20/1961 LIP AB Elem. Grad. Carpenter Roman Catholic None
Lopez, Elliang Seña Wife Female 58 9/15/1961 LIP O None None Roman Catholic
SHARER
Villaranda, Germinigilda Mother Female 36 2/5/1982 W O Elem. Grad. None Roman Catholic None
Villaranda, Criselda Daughter Female 17 4/7/2002 S Grade 12 Student 0997-523-1157 Roman Catholic
Villaranda, Cristian Son Male 15 11/29/2004 S Grade 9 Student Roman Catholic
Villaranda, Chelsie Daughter Female 6 1/11/2013 S Grade 1 Student Roman Catholic
Villaranda, Carlo James Son Male 10 1/7/2009 S Grade 5 Student Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specify) ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts) / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 20 years Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Villarez, Arsenio Brosola Head Male 73 4/30/1946 SEP-FM Elem. Grad. Carpenter Roman Catholic member-SC
SHARER
Villarez, Jhon Carlo Armada Father Male 26 11/16/1992 M HS Grad. Painter Voluntary
Villarez, Roxanne Navarro Wife Female 25 12/11/1993 M HS Grad. D.H.
Villarez, Carla Jane Daughter Female 6 10/26/2013
Villarez, Princess Lara Daughter Female 4 8/25/2015
Villarez, Carl Saidon Son Male 2 8/3/2017

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specify) ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts) / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 30 years Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Villarez, Carlito Brosola Head Male 67 12/29/1951 SEP Painter 0936-778-6525 Roman Catholic Sponsored-Gov.
SHARER
Villarez, Carvilito Armada Son Male 32 1/14/1987 LIP HS Grad. Painter Roman Catholic Member-Voluntary
Torres, Kelly Wife Female 23 8/7/1996 LIP HS Grad. None Roman Catholic
Villarez, Kclyn Torres Daughter Female 2 6/19/2017 Roman Catholic
Villarez, Keithlyn Grace Torres Daughter Female 1 mos. 8/29/2019 Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specify) ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts) / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 1 year Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Blanca, Andrew John Roque Head Male 31 9/14/1988 CL-MF HS Grad. Technician Roman Catholic Member-Voluntary
Caballero, Michelle - LIP Female 31 1/10/1988 CL-MF HS Grad. 0935-395-2436 Roman Catholic Member-Voluntary
Blanco, Brave Caballero Son Male 5 10/25/2018 kKinder Student Roman Catholic D-D of mother

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned / Rented Others (specify) ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts) / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 20 years Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Bascuguin, Gil Bautista Head Male 49 10/24/1970 M Elem. Grad. Tricycle Driver Roman Catholic
Bascuguin, Cristina Perez Wife Female 44 4/25/1975 M College Grad. Teacher 0955-925-8567 Roman Catholic Member
Bascuguin, Ian Perez Son Male 21 2/26/1998 S HS Grad. None Roman Catholic D
Bascuguin, Lexter Perez Son Male 18 11/17/2000 S SHS Grad. Student Roman Catholic D
Bascuguin, Gwen Perez Daughter Female 9 6/19/2010 S Grade 4 Student Roman Catholic D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specify) ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify) ____________________

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts) / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specify) ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: Private/DRA. BELVIS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 40 years Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Panaligan, Leo Catchillar Head Male 63 10/27/1956 M HS Grad. Retired Employee Roman Catholic Member-lifetime
Panaligan, Lionida Ramos Wife Female 63 5/22/1956 M College Grad. None Roman Catholic Member-SC
Panaligan, Krizzha Penol Grand Daughter Female 14 10/4/2005 Grade 9 Student Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specif ____________________

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts) / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 9 years Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Torres, Emie Yumang Mother Female 53 8/26/1966 HS Grad. None 0936-778-6524 Roman Catholic Member-indigent
Castillo, Kurt Torres Son Male 15 9/5/2004 S Grade 10 Student Roman Catholic
Castillo, Kyle Torres Son Male 13 10/14/2006 S Grade 9 Student Roman Catholic
Castillo, Kurt Ivan Torres Son Male 12 10/4/2007 S Grade 7 Student

Roman, Jan Justine Gonzaga Grandson Male 12 7/6/2007 Grade 7 Roman Catholic

Torres, Gemkarl Son Male 21 10/15/1998 M SHS Grad. Market Vendor Roman Catholic Voluntary
Torres, Merjorie Andino Daughter in law Female 20 1/26/1999 M SHS Grad. None Roman Catholic
Torres, Bleissy Andino Grandson Male 2mos. 7/21/2019

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specif ____________________

2.       Water Supply

a. Source / Level I (Point Source) Level II (Communal or Stand Posts) Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH/DR. LAYLO
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 11 years Mobile Number or Email Address (optional):
Complete Address:

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Vergara, Liberato Javier Head Male 57 8/17/1962 M O HS Grad. Laborer/ Tanod SDA Member-indigent
Vergara, Maria Elena Alegre Wife Female 53 7/20/1966 M O College Grad. BWS 0936-155-1661 Christian Member-indigent
Vergara, Louella Jane A. Daughter Female 21 4/27/1998 S HS Grad. None Roman Catholic None
Vergara, Marielle Joy Alegre Daughter Female 19 4/7/2000 S HS Grad. TGP-Employee Roman Catholic 1D
Vergara, Albert John Alegre Son Male 19 4/8/2000 S HS Grad. None Roman Catholic 1D
Vergara, Justin Alegre Son Male 14 9/3/2005 S Grade 9 Student Roman Catholic 1D
Vergara, Junelle Alegre Son Male 12 11/22/2006 S Grade 7 Student Roman Catholic 1D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: / Light Strong Mixed Others
c. Lighting Facilities Electicity Kerosene Others (specif Rechargeable Light/ Candle

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) / Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water?DEEP WELL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding / Open Burning / Open Dumping Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. 9 BHW
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 37 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Martos, Gilmar Sistona Head Male 36 1/5/1982 CL-MF None Brgy. Councilor 0997-946-0025 Roman Catholic Member-sponsor
Estadilla, Maricel Pribada Wife Female 31 1/8/1988 CL-MF Elem. Grad. Roman Catholic Direct
Martos, Gemalyn Samonte Daughter Female 15 6/30/2004 S Grade 10 Roman Catholic
Martos, Syra Mae Samonte Daughter Female 10 7/21/2009 S Grade 5 Roman Catholic
Martos, Gemcel Estadilla Son Male 5 7/13/2014 S Kinder Roman Catholic
Martos, Gizzelle Estadilla Daughter Female 3 9/24/2016 S

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specif Candle

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? DISTILLED WATER
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. 9 BHW
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 19 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Soreta, Manny Bahia Head Male 36 12/5/1982 CL-MF None Brgy. Police Roman Catholic Member-sponsor
Pangan, Carmensita LIP Female 39 10/29/1980 CL-MF Elem. Grad. Utility 0936-136-0064 Roman Catholic
Soreta, Maica Pangan Daughter Female 17 12/12.2001 S Elem. Grad. Dishwasher Roman Catholic D
Soreta, Jude Michael Pangan Son Male 17 3/8/2002 S None Helper Roman Catholic D
Soreta, Jhon Bon Jovie Pangan Son Male 12 2/15/2007 S Grade 7 Student Roman Catholic D
Soreta, Jhon Kervin Pangan Son Male 10 12/31/2008 S Grade3 Student Roman Catholic D
Soreta, Mecaila Pangan Daughter Female 6 4/11/2013 Grade 1 Student Roman Catholic D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities Electicity Kerosene / Others (specif Candle

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 34 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Raagas, Eduardo Dagali Head Male 62 10/17/1957 W AB None None Roman Catholic None

Nicolas, Richard Acar Head Female 34 5/10/1985 CL-MF O Elem. Grad. Welder Roman Catholic
Raagas,Edcarmelyn Espinilla Wife Female 32 6/19/1987 CL-MF HS Grad. BHW 0926-459-5834 BA
Nicolas, John Cloe Raaga Son Male 13 7/25/2006 S O Grade 8 Student Roman Catholic
Nicolas, Trixie Joy Raagas Daughter Female 11 6/4/2008 S Grade 6 Student Roman Catholic
Nicolas, Charice Yvone Raagas Daughter Female 10 9/7/2009 S Grade 5 Student Roman Catholic
Nicolas, Sophia Faye Raagas Daughter Female 7 12/30/2011 S Grade 2 Student BA
Nicolas, Prince Cedrick Raagas Son Male 6 9/12/2013 S Grade 1 BA
Nicolas, Alyssa Mae Raagas Daughter Female 3 6/22/2016 S BA

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) Covered container / uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN/DRA. NOCHE
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 13 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Armada, Arman Leviña Head Male 38 2/6/1981 M Elem. Grad. Painter Roman Catholic D.D.
Armada, Rowena Casanova Wife Female 38 11/23/1980 M HS Grad. Lady Guard 0926-952-8912 Roman Catholic Member-Private
Armada, Ma. Arwen Casanova Daughter Female 15 10/11/2004 S Grade 9 Student Roman Catholic D.D.
Armada, Ma. Arren Casanova Daughter Female 9 9/22/2010 S Grade 5 Student Roman Catholic D.D.

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN/DRA. NOCHE
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 13 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Alicando, Alberto Garcia Head Male 54 12/15/1965 M Elem. Grad. Fisherman 0906-814-9593 Jehovas Witnesses Member- Indirect
Alicando, Aileen Perez Wife Female 52 12/18/1967 M Elem. Grad. House Wife Roman Catholic D
Alicando, Allan Perez Son Male 32 11/8/1987 S HS Grad. Vendor Roman Catholic None
Alicando, Alfred Perez Son Male 26 1/20/1993 S Elem. Grad. Carwash Boy 0997-487-3799 Roman Catholic None
Alicando, Bert Perez Son Male 15 10/19/2004 S Grade 8 Student Jehovas Witnesses D
Alicando, Totoy Perez Son Male 14 10/5/2005 S Grade 7 Student Jehovas Witnesses D
Alicando, Aiza Perez Daughter Female 12 10/9/2007 S Grade 7 Student Jehovas Witnesses D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: Light Strong / Mixed Others
c. Lighting Facilities Electicity / Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container / Covered uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 11 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Magyaya, Corazon Millar Head Female 52 2/22/1967 W Elem. Grad. Vendor 0997-253-6154 Roman Catholic None
Magyaya, Mark Aldren Millar Son Male 30 5/12/1989 S HS Grad. none-HTI Roman Catholic Member-private
Magyaya, Mark Aries Millar Son Male 24 1/20/1995 S HS Grad. OFW Roman Catholic Member-private
Sharer
Magyaya, Mark Andrew Millar Father Male 28 3/22/1991 CL-MF HS Grad. Vendor Roman Catholic Member- not active
Rufa, Pinky Rose LIP Female 23 10/13/1996 CL-MF HS Grad. Sales Lady Roman Catholic Member- private
Magyaya, Paul Andrei Rufa Son Male 6 4/28/2013 S Kinder Student Roman Catholic D-D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: Light Strong / Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 11 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Delas Alas, Alberto Garcia Head Male 58 11/10/1960 M None Carpenter Roman Catholic Member-NHTS
Delas Alas, Evangeline Domingo Wife Female 50 1/8/1969 M HS Grad. Helper 0936-186-8089 Roman Catholic 1-D
Delas Alas, Charles Domingo Son Male 24 2/15/1995 HS Grad. Poster-NAIA Roman Catholic Member-private
Delas Alas, Jackielyn Domingo Daughter Female 28 11/17/1991 Elem. Grad. Sales Lady Roman Catholic Member-private
Delas Alas, Janet Domingo Daughter Female 15 9/11/2004 Grade 8 Student Roman Catholic 1-D
Delas Alas, Jhon Carlo Domingo Son Male 12 8/10/2007 Grade 2 Student Roman Catholic 1-D
Domingo, Jocel Asuncion Niece Female 11 10/8/2008 Grade 2 Student Roman Catholic
Delas Alas, Abigail Domingo Grand Daughter Female 3 6/26/2016 D of mother

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (specif ____________________
b. Type of Construction Material: Light Strong / Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (specif ____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 49 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Soreta, Helen Bahia Head Female 69 7/20/1950 None Labandera Roman Catholic Member-SC
Soreta, Jinggoy Grand Son Male 20 6/23/1999 None Construction Worker Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities Electicity / Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHC
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 25 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Calaud, Enrico Bagay Head Male 49 11/24/1969 M None Businessman 0965-456-5748 Roman Catholic Member-voluntary
Calaud, Dolores Sistona Wife Female 52 9/18/1967 M Elem. Grad. None Roman Catholic
Calaud, Ricardo Sistona Son Male 25 10/20/1994 College Grad. Helper(emperador) Roman Catholic
Calaud, Jerico Sistona Son Male 23 4/12/1996 HS Grad. None Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? GRIPO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 32 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Soreta, Teressa Alcomenda Head Female 50 3/1/1969 CL-FF None Brgy. Police 0955-159-6235 Roman Catholic None
Espinar, Anchinita Sistona Female 51 12/10/1968 CL-FF Elem. Grad. Utility Roman Catholic None
Soreta, Cristian Jess Alcomenda Son Male 24 12/25/1994 Elem. Grad. Roman Catholic None
Soreta, John Mark Alcomenda Son Male 11 7/27/2008 Grade 5 Student Roman Catholic None

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: / Light Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 7 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Nocillas, Michael Simvilla Head Male 29 5/13/1990 CL-MP None Vendor 0997-679-8413 Roman Catholic Member-voluntary
Soreta, Rachel Alcomendez Wife Female 31 2/13/1988 CL-MP Elem. Grad. None Roman Catholic
Nocillas, John Michael Soreta Son Male 9 3/4/2010 Grade 4 Student Roman Catholic
Nocillas, Steve Nash Soreta Son Male 6 4/4/2013 Grade 1 Student Roman Catholic
Nocillas, Princess Shelly Soreta Daughter Female 1 1/22/2018

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned Rented / Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL WATER
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 43 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Dela Cruz, Charlie Head Male 64 9/5/1955 M B None None Roman Catholic Member-SC
Dela Cruz, Marita Soreta Wife Female 62 5/10/1957 M A Elem. Grad. None 0936-268-6917 Roman Catholic Member-SC

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BALAYAN RHU
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 43 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Soreta, Eusebio Sistona Head Male 47 11/5/1971 CL-MF O Elem. Grad. Fisherman Roman Catholic Member-Indigent
Mondragon, Gina Zebial Wife Female 43 6/8/1976 CL-MF O Elem. Grad. Kasambahay Roman Catholic
Soreta, John Harvey Mondragon Son Male 8 12/11/2010 S Grade 2 Roman Catholic
Soreta, John HardyMondragon Son Male 7 8/19/2012 S Roman Catholic
Soreta, Hariett Mondragon Daughter Female 2 2/10/2017 S Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source / Level I (Point Source) Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BALAYAN RHU
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 26 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Vallesteros, Eusebio Delos Reyes Head Male 48 2/23/1971 M Elem. Grad. Tricycle Driver Roman Catholic None
Vallesteros, Jasmine Soreta Wife Female 43 5/8/1976 M None Labandera Roman Catholic
Vallesteros, Joyce Ann Soreta Daughter Female 20 3/21/1999 S SHS Grad. Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container / Covered uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 20 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Dalida, Daryll Jhon Cruzat Head Male 21 7/31/1998 CL-MF College Student Student Roman Catholic None
Adona, Mary Jane Orence Wife Female 18 12/27/2000 CL-MF Grade 12 Student Roman Catholic
Dalida, Diana Divine Adona Daughter Female 18mos. 2/16/2017 S

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 68 years Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Dalida, Reynaldo Nadong Head Male 68 1/29/1951 M HS Grad. None BA Member-SC

Dalida, Germilinda Samillano Wife Female 63 1/17/1956 M Elem. Grad. None BA Member-SC
Dalida, Ryan Samillano Son Male 33 10/18/1986 Security Guard Roman Catholic Member-Private
Dalida, Davey Reynalyn Samillano Daughter Female 21 4/27/1998 Trainor BA D
Dalida, Dave Jetro Samillano Son Male 18 10/23/2001 Grade 11 Student Roman Catholic D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Sulit, Nida Ganti Head Male 61 4/10/1958 W B None None Roman Catholic Member-SC
Santos, Maricel Sulit Daughter Female 42 1/27/1977 S None None Roman Catholic Dependent

Santos, Vilmar Sulit Head Male 36 7/12/1983 CL-MF B None Fisherman Roman Catholic Member-Indigent
Hernandez, Gladys Cabral Wife Female 32 9/27/1987 CL-MF B None None 0955-392-4455 Roman Catholic Member-Indigent
Santos, Mark Aron Hernandez Son Male 13 9/20/2006 LIP B Grade 7 Student Roman Catholic
Santos, John Marwen Hernandez Son Male 11 2/22/2008 S B Grade 5 Student Roman Catholic
Santos, Princess Ruzzel Hernandez Son Male 4 8/15/2015 S B

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary / None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 36 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Barquilla, Prescious Martos Head Male 36 8/3/1983 SEP HS Grad. None Roman Catholic Member-voluntary
Barquilla, Donna Mae Martos Daughter Female 18 8/7/2001 Grade 12 Student Roman Catholic
Barquilla, Jhon Dave Martos Son Male 16 1/12/2003 Grade 11 Student Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 19 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Balboa, Jay Ocampo Head Male 44 1/24/1975 M College Grad. None BA Member-self employed
Balboa, Debbie Dalida Wife Female 42 8/31/1976 M College Grad. Secretary BA Member-private
Balboa, Andre lyn Dalida Female 17 7/9/2002 HS Grad. Student BA D
Balboa, Jade Dalida 11 9/29/2008 Grade 6 Student BA D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH/DR. PANALIGAN
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 1 yr. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Campado, Gideone Froyalde Head Male 50 5/29/1969 CL-MF Elem. Grad. Truck Driver Roman Catholic None
Roxas, Gina Mendiola LIP Female 58 2/7/1960 CL-MF None None Roman Catholic None

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned / Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes No Both
If no, where do you get your drinking water? WRS
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 5 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Perez, Rene Bautista Head Male 44 11/11/1974 M HS Grad. Carpenter BA Member- Voluntary
Perez, Conception Dalida Wife Female 48 12/8/1970 M HS Grad. None 0955-370-2459 BA D
Perez, Mikylla Dalida Daughter Female 14 10/26/2005 Grade 8 Student BA D
Perez, kayesalyn Dalida Daughter Female 12 3/10/2007 Grade 6 Student BA D
Perez, Trisha Dalida Daughter Female 11 5/7/2008 Grade 6 Student BA D
Perez, Rence Aron Dalida Son Male 10 11/23/2009 Grade 4 Student BA D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH/DR. LAYLO
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 1 yr. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Armada, Salvacion Levina Head Female 73 1/9/1946 M None None BA Member-SC

Armada, Arthuro Jr. Levina Son Male 52 4/24/1967 S None Baker BA

Armada, Joel Levina Head Male 48 5/16/1971 M Elem. Grad. Brgy. Captain BA Member
Armada, Dezibeth Nicolas Wife Female 44 12/28/1974 M None BHW 0905-592-3950 BA Member
Armada, Judilyn Nicolas Daughter Female 23 11/12/1995 S College Grad. BA
Villarez, Sandie Gie Angela Nicolas Grand Daughter Female 13 4/4/2006 S Grade 8 Student BA

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned / Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered uncovered
ii. Segregated Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth. Incomplete info.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 17 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Lerio, Jofferd Abanilla Head Male 34 9/23/1995 M HS Grad. Trainor 0935-218-6842 Roman Catholic Member-Private
Lerio, Evangelyn Alicando Wife Female 23 2/14/1996 M HS Grad. House wife 0965-617-1386 Jehovas witness

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: / Light Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 63 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Dalida, Nora Rodriguez Head Female 69 2/27/1950 W Elem. Grad. None Baptist Member-SC

Dalida, Vhon Heindric Aquino Male 29 9/1/1990 Elem. Grad. Roman Catholic
Dalida, Kelvin Aquino Male 27 11/14/1991 Elem. Grad. Laborer Roman Catholic
Africa, Jhon Raven Dalida Male 26 9/10/1993 College Grad. Baptist
Africa, Jazelle Dalida Female 24 12/10/1994 HS Grad. Free Lance Baptist
Dalida, Andrea Lianzon Female 19 11/19/2000 None
Dalida, Kristopher John Rodriguez Male 19 8/24/2000

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 15 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Ermita, Apolonio Custodio Head Male 59 2/9/1960 CL-MF None Business Owner 0935-498-8137 Roman Catholic Member-Voluntary
Tolentino, Cerelina Liamolo LIP Female 43 8/9/1976 MF None

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? GRIPO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 17 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

De Leon, Kristopher Head Male 34 5/12/1985 M O HS Grad. Worker (Glass Ware) Roman Catholic Member
De Leon, Aprilita Manalo Wife Female 31 4/3/1988 M O HS Grad. None 0975-851-8923 Roman Catholic
De Leon, Harry Manalo Son Male 6 10/29/2016 Grade 1 Student Roman Catholic
De Leon, Harley Manalo Son Male 6 10/29/2016 Grade 1 Student Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 43 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Dela Cruz, Roberto Soreta Head Male 45 3/15/1974 CL-MF Elem. Grad. Mun. Employee 0936-096-6009 Roman Catholic Member-Private
De Leon, Liovina Akbang Wife Female 53 3/13/1966 CL-MF Elem. Grad. None Roman Catholic
Dela Cruz, Ronbert Castor Son Male 15 8/10/2004 Grade 8 Student Roman Catholic D-D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 4 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Hernandez, Roderick Dimailig Head Male 47 7/11/1972 CL-MF HS Grad. Mason Roman Catholic None
Rufa, Emerlyn Atienza Wife Female 37 1/28/1982 CL-MF None None 0955-944-3524 BA Member-Indigent
Rufa, Ericka Mae Atienza Daughter Female 11 10/3/2008 Grade 6 Student BA
Hernandez, Angel Joy Rufa Daughter Female 5 10/27/2014 Day Care Student BA

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light Strong / Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary / None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Raagas, Jayson Espinilla Head Male 37 4/14/1980 S None Paintor 0905-581-5748 Roman Catholic Member-4ps
Raagas, Jay Ann Mondero Daughter Female 11 10/8/2008 S Grade 5 Student Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes No / Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary / None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Aldave, Angelito Gaa Head Male 48 10/4/1971 M HS Grad. OFW Roman Catholic Member-MW
Aldave, Alma Seña Wife Female 47 5/6/1972 M HS Grad. BHW Roman Catholic D
Aldave, David Jonathan Seña Son Male 26 8/31/1993 S HS Grad. Student Roman Catholic None
Aldave, David Angelo Seña Son Male 18 3/14/2001 S HS Grad. Student Roman Catholic None
Aldave, Hanna Jayjay Nicole Seña Daughter Female 21 9/29/1998 S SHS Grad. Student Roman Catholic None

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No / Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 22 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Pornabe, Rose Divina Head Male 55 3/16/1964 W None Cleansing the bottle 0906-708-1720 INC Sponsored-Gov.
Castrojeres, Rodilyn Pornabe Daughter Female 25 11/28/1993 S Hunchback person None House maid Born again Sponsored
Castrojeres, Alberto Pornabe Son Male 13 12/5/2005 S Grade 8 Student INC
Castrojeres, Mikos Pornabe Son Male 16 2/24/2003 S Grade 5 Student INC
Castrojeres, Mioises Pornabe Son Male 21 7/14/1998 S Elem Grad. Steel Man INC Member- Private
Castrojeres, Roderico Pornabe Son Male 33 8/4/1986 Elem Grad. Steel Man INC Member- Private
De Leola, Maristel Amores Grand Daughter Female 16 2/5/2003 S Grade 11 Student Born again
De Leola, Glenn Grandson Male 15 8/6/2004 Grade9 Student INC

Castrojeres, Renato Pornabe Son Male 30 2/26/1992 LIP-MF HS Grad. Steel Man Roman Catholic Member-Private
Castrojeres, Michelle Pornobe Daughter in Law Female LIP-MF Waitress Roman Catholic
Castrjeres, Romeo Pornobe Son Male 28 7/4/1991 LIP-MF Elem. Grad. Tricycle Driver Roman Catholic Sponsored-Private
Ciervo, Reynabelle Daughter in Law Female 21 6/25/1998 LIP-MF Elem. Grad. Waitress Roman Catholic Sponsored-Private
Castrojeres, John Sedrick Ciervo Son Male 4 9/22/2015 Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source / Level I (Point Source) Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking / Yes No / Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
/ Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 20 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Dalida, Dexter Rodriguez Head Male 47 10/20/1972 CL-MF Voc. Grad. OFW Roman Catholic Member-MW
Delos Reyes, Antonina Patulay Wife Female 57 1/10/1962 CL-MF Elem. Grad. None 0930-001-1602 Roman Catholic None
Dalida, Jeric Delos Reyes Son Male 19 4/29/2000 None Roman Catholic
Sharer
Dalida, Joshua Ivan Delos Reyes Father Male 22 10/8/1997 CL-MF HS Grad. None Roman Catholic Member-not active
Sistona, Melanie Grego Wife Female 20 3/5/1999 CL-MF HS Grad. SK Chairman Roman Catholic Member
Dalida, Daniel Ivan Sistona Son Male 1mo. 9/8/2019 Roman Catholic D-mother

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 25 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Dela Cruz, Cristoval Soreta Head Male 42 7/12/1977 M Elem. Grad. Fisherman 0927-293-2844 Roman Catholic
Dela Cruz, Janeth Zapanta Wife Female 44 9/24/1975 M Voc. Grad. None Roman Catholic Sponsored-Gov.
Dela Cruz, Jocris Zapata Son Male 23 5/16/1996 S HS Grad. None Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? GRIPO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping Garbage Collection
/ Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 3 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Aquino, George Cordero Head Male 56 4/13/1963 CL-MF HS Grad. Welder 0927-096-4847 Roman Catholic None
Soreta, Allen Bahia LIP Female 43 6/20/1976 CL-MF None None Roman Catholic Member-Voluntary
Aquino, John Paul Soreta Son Male 3 6/6/2016 S Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: RHU BALAYAN
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 11 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Seña, Noel Head Male 50 7/9/1969 Elem. Grad. Construction worker INC Member-Indigent
Ramos, Divina Wife Female 38 2/8/1981 Elem. Grad. None BA Member-4ps
Seña, Dea Ramos Daughter Female 13 2/28/2006 Grade 7 Student BA D-father
Seña, Joyce Ann Ramos Daughter Female 11 6/13/2008 Grade 5 Student BA D-father
Seña, Jhon Carl Ramos Son Male 8 6/6/2011 Grade 2 Student BA D-father
Seña, Jhon Luis Ramos Son Male 6 5/10/2013 Kinder Student BA D-father

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned / Rented Others (spe____________________
b. Type of Construction Material: Light Strong / Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DR. LAYLO/ DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 50 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Badillo, Rufino Atienza Head Male 60 4/7/1959 S None Maintenance/ House Boy Roman Catholic None

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: / Light Strong / Mixed Others
c. Lighting Facilities Electicity Kerosene / Others (specify) None

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered uncovered
ii. Segregated Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary / None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DR. LAYLO/ DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 39 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Baqui, Anselmo Panganiban Head Male 59 4/21/1960 M Elem. Grad. BRGY. Councilor Roman Catholic Member-Indigent
Baqui, Carmelita Badillo Wife Female 54 8/23/1964 M Elem. Grad. None 0916-996-0673 Roman Catholic 1-D
Sharer
Baqui, Elmo Jun Badillo Father Male 25 3/25/1994 M Elem. Grad. Trucking/Pahinante Roman Catholic None
Baqui, Jennifer Dastas Mother Female 25 8/25/1994 M HS Grad. BHW Roman Catholic None
Baqui, Lara Mae Dastas Daughter Female 5 10/17/2014 Day care Roman Catholic None

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DR. LAYLO/ DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 9 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Baque, Augusto Badillo Head Male 38 8/12/1981 M None Driver Roman Catholic Member-Voluntary
Baque, Kristine Arellano Wife Female 35 9/23/1984 M HS Grad. None 0975-658-0310 Roman Catholic D-D
Baque, Ryan Jay Arellano Son Male 14 6/11/2005 Grade 9 Student D-D
Baque, Princess Joy Arellano Daughter Female 9 5/8/2010 Grade 3 Student Roman Catholic D-D
Baque, John Ray Arellano Son Male 1&11mos. 11/14/2018 Roman Catholic D-D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS/B9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 36 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Baque, Maximiano Panganiban Head Male 66 4/21/1953 CL None Brgy. Police Roman Catholic Member-sponsored
Martos, Prisula sistona LIP Female 62 2/10/1957 CL None None Roman Catholic Member

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking Yes No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 2 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Magnaye, Reynaldo Discalles Head Male 43 2/17/1976 M None Tricycle Driver 0936-815-0512 Roman Catholic Member-sponsored
Magnaye, Josephine Magsino Wife Female 40 2/20/1979 M None None Roman Catholic
Magnaye, Ron Joseph Magsino Son Male 22 2/20/1997 S None Tricycle Driver Roman Catholic
Magnaye, Reynaldo Jr. Magsino Son Male 19 11/30/2000 S None Cook Roman Catholic
Magnaye, Jhon Carlo Magsino Son Male 15 1/3/2004 Grade 5 Student Roman Catholic
Magnaye, Michael Angelo Magsino Son Male 11 11/2/2007 Grade 3 Student Roman Catholic
Magnaye, Princess Magsino Daughter Female 9 12/29/2009 Grade 3 Student Roman Catholic
Magnaye, Patricia Mae Magsino Daughter Female 7 9/28/2012 Grade 1 Student Roman Catholic
Magnaye, Mark Jay Magsino Son Male 2 8/5/2017 Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 35 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Manoguid, Andy Sarmiento Head Male 44 8/21/1975 M O College Grad. Tricycle Driver 0965-085-0204 Roman Catholic Member-Voluntary
Manoguid, Erica Baque Wife Female 35 3/10/1984 M AB Elem. Grad. None Roman Catholic
Manoguid, Janice Baque Daughter Female 18 1/23/2001 S SHS Grad. Sales Lady Roman Catholic
Manoguid, John Mackearl Baque Son Male 16 4/28/2003 S Grade 11 Student Roman Catholic
Manoguid, Ayne Joie Baque Daughter Female 13 12/17/2005 Grade 9 Student Roman Catholic
Manoguid, Andrew Baque Son Male 8 1/8/2011 Grade 3 Student Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned / Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source / Level I (Point Source) Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking Yes No Both
If no, where do you get your drinking water? MINERAL WATER
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BALAYAN RHU
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 35 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Magsino, Ramilito Pallet Head Male 46 8/19/1973 M AB Elem. Grad. Tricycle Driver 0997-613-5295 B.A. Member-Brgy.
Magsino, Maxima Samonte Wife Female 43 5/29/1976 M Elem. Grad. Vendor B.A.
Magsino, Emilito Samonte Son Male 25 9/16/1994 LIP HS Grad. Brgy. Sec. B.A.
Magsino, Romenick Samonte Son Male 23 2/7/1996 LIP HS Grad. B.A.
Magsino, Ramilyn Samonte Daughter Female 20 5/19/1999 S HS Grad. Singer B.A.
Magsino, Rhamiel Samonte Son Male 10 2/1/2009 S Grade 5 Student B.A.

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container / Covered uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DMLMDH
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 5 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Francisco, Gerald Delos Reyes Head Male 29 5/3/1990 CL-MF Elem. Grad. Fruit Vendor Member-Voluntary
Soreta, Leizl Alcomedes Wife Female 29 10/4/1990 CL-MF Elem. Grad. None Member-Voluntary
Francisco, Carlos Miguel Soreta Son Male 6 5/10/2013 Grade 1 Student D-Mother
Francisco, Leslie Joy Soreta Daughter Female 4 8/2/2015 D-Mother
Francisco, Ashley Jane Soreta Daughter Female 2 8/1/2017 D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light Strong / Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: B9/BHW
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Dela Cruz, Raymart Castor Head Male 28 1/8/1991 CL-MF Elem. Grad. Security Gurad Roman Catholic Member-Indigent
Burato, Bonalyn Gayos Wife Female 30 5/29/1989 CL-MF Elem. Grad. None Member-Voluntary
Dela Cruz, Rhian Burato Daughter Female 7 2/16/2012 Grade 2 Student
Dela Cruz, Rhiana Burato Daughter Female 1 12/30/2017

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary / None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: B9/BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 2 months Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Armada, Judirick Nicolas Head Male 22 1/8/1997 M HS Grad. Paintor B.A.

Armada, Cristy Barlovento Wife Female 20 8/6/1999 M HS Grad. none 0926-921-8431 B.A. Member

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DR. LAYLO
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 40 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Cervas, Nickson Sebastian Head Male 42 1/17/1976 M HS Grad. Security Guard Roman Catholic Member-Private
Cervas, Laila Bagay Wife Female 39 10/27/1979 M HS Grad. Lady Guard 0909-845-7870 B.A. Member-Private
Cervas, Ashley Nicole Cervas Daughter Female 14 8/18/2005 S Grade 9 B.A.

Bagay, Mavin Baller Brother Male 38 12/7/1981 S None None B.A.

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Aldave, Gil Dela Torre Head Male 71 7/7/1948 M O None None Roman Catholic Member-SC
Aldave, Gloria Mortera Wife Female 71 8/3/1948 M B None None 0995-360-1969 Roman Catholic Member-SC

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DON MANUEL LOPEZ HOSPITAL
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 64 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Balboa, Laura Sistona Female 63 10/19/1954 B Elem. Grad. None 0905-5925935 Roman Catholic Senior
Bascuguin, Amyluz Cenas Mother Female 4 9/13/1995 HS Grad. OFW Roman Catholic Member-MN
Cenas, Christian Kurt Bascuguin Grand son Male 25 10/16/2015

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BALAYAN RHU
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 10 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Balboa, Anthony Sistona Head Male 44 6/13/1975 CL-MF Elem. Grad. Paintor N/A Roman Catholic Member-Indigent
Garcia, Shirley Tanaingan Wife Female 35 4/8/1984 CL-MF HS Grad. Utility Roman Catholic None
Balboa, Robert Garcia Son Male 8 1/29/2011 Grade 2 Student Roman Catholic 1-D
Balboa, Nathalie Garcia Daughter Female 6 7/26/2013 None Roman Catholic 1-D
Camasora, Jhobert Son Male 17 1/4/2002 Grade 6 (stopped) Paintor Roman Catholic 1-D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 7 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Balboa, Eric Sistona Head Male 35 8/13/1984 CL-MF Elem. Grad. Paintor Roman Catholic None
Lacaden, Carla Mae Atienza Wife Female 24 2/20/1995 CL-MF Elem. Grad. Roman Catholic None

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? GRIPO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary unsanitary / None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BARANGAY HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Balboa, Victor Sistona Head Male 46 7/23/1973 CL None Fisherman Roman Catholic Member-Indigent
Bergado, Maricel De Guzman Wife Female 32 3/12/1987 CL Elem. Grad. Labandera 0936-663-0995 Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage None (direct from faucet) / Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water? GRIPO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BARANGAY HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Ramirez, Federico Gagatiga Head Male 51 4/30/1968 M HS Grad. Businessman 0935-754-2031 J.W None
Ramirez, Marites Guardian Wife Female 53 11/23/1965 M HS Grad. vendor J.W 4ps
Ramirez, Jomar Guardian Son Male 31 12/30/1987 S College Grad. 0910-745-5654 Roman Catholic Member-Private
Ramirez, Jemalyn Guardian Daughter Female 30 2/8/1989 S College Grad. Call Center agent 0935-864-1900 Roman Catholic Member-Private
Ramirez, Jaymark Guardian Son Male 28 1/13/1991 S College Grad. Receptionist 0905-071-0339 Roman Catholic Member-Private
Ramirez, Jude Mark Guardian Son Male 23 2/10/1996 S College Grad. Technician 0936-155-0531 Roman Catholic Member-Private
Ramirez, John Martin Guardian Son Male 17 6/15/2002 S Grade 12 Student 0905-904-5937 J.W

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BARANGAY HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Sistona, Liticia Grego Head Female 50 10/1/1969 LIP-F None House Maid 0905-581-8120 Roman Catholic Member-Voluntary
Sistona, Marlon Grego Son Male 24 10/22/1994 S HS Grad. Lineman Roman Catholic
Sistona, Mylene Grego Daughter Female 26 5/3/1993 HS Grad. None Roman Catholic
Sistona, Shin Lorraine Grandson Female 9 12/30/2018 Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BALAYAN RHU/ DRA. NOCHE
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 2yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Roxas, Enrico Pantoja Head Male 53 8/20/1966 M Elem. Grad. Fisherman Roman Catholic D
Roxas, Elsie Arquileta Wife Female 56 2/11/1963 M College Grad. None 0945-086-6267 Roman Catholic Member-Voluntary
Roxas, Mark Lester Arquileta Son Male 33 3/23/1986 S HS Grad. Merchandizer Roman Catholic Member-Private
Roxas, Mae Leslie Arquileta Daughter Female 30 6/30/1989 M/Sep HS Grad. OFW Roman Catholic Member-Migrant worker
Roxas, Maria Lyncel Arquileta Daughter Female 26 8/4/1992 S HS Grad. OFW Roman Catholic Member-Migrant worker
Santos, Keishena Mae Roxas Grand Daughter Female 8 8/10/2011 Grade 3 Student Roman Catholic D
Mangubat, Don roxas Grand Son Male 5 7/24/2014 Kinder Student Roman Catholic D
Santos, Khelie Mae Roxas Grand Daughter Female 10 10/30/2009 Grade 5 Student Roman Catholic D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

mber-Migrant worker
mber-Migrant worker
 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BRGY. HEALTH CENTER
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Balasabas, Jayson Navaro Head Male 29 9/1/1990 M None Fisherman 0955-618-8627 Roman Catholic Voluntary
Balasabas, Rochele Lasac Wife Female 27 7/1/1992 M Elem. Grad. None Roman Catholic
Balasabas, Jayzel Lasac Son Male 7 3/3/2012 Grade 1 Student Roman Catholic
Balasabas, Jayron Lasac Son Male 5 1/3/2014 Grade 1 Student Roman Catholic
Balasabas, Jayronzel Lasac Son Male 2 12/25/2016 Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light Strong / Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth.

 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider:
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Balboa, Roger Sistona Head Male 40 10/9/1979 M Roman Catholic

Balboa, Emiliana Ramirez Wife Female 39 9/11/1980 M Roman Catholic
Balboa, Tracy Ramirez Daughter Female 16 10/15/2003 Roman Catholic
Balboa, Mark Railey Ramirez Son Male 15 9/25/2004 Roman Catholic
Balboa, Cyril Mae Ramirez Daughter Female 13 5/9/2006 Roman Catholic
Balboa, Ronian Ramirez Son Male 11 4/20/2008

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light Strong / Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? MINERAL
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: DR. RAMOS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Sistona, Rodolfo Cabrera Head Male 70 5/5/1949 M O None Vendor Roman Catholic Member-SC
Sistona, Aurora Arcal Wife Female 60 7/5/1959 M O Elem. Grad. Vendor Roman Catholic Member-SC
Sistona, Wilbert Arcal Son Male 34 4/10/1985 HS Grad. Fisherman Roman Catholic Member
Sharer
Sistona, Edward Arcal Head Male 39 5/24/1980 CL-MF O HS Grad. Gov. employee Roman Catholic Member
Montillana, Myrna LIP Female 31 9/1/1988 CL-MF HS Grad. None Roman Catholic Member
Sistona, Gillian Joy Montillana Daughter Female 10 6/29/2009 S Grade 5 Student Roman Catholic
Sistona, Mark Joshua Montillana Son Male 7 9/2/2012 S Grade 1 Student Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider:
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Cruz, Nestor Gloria Head Male 48 10/14/1971 CL-MF Elem. Grad. Paintor Roman Catholic
Edongan, Mary Ann Quiambao Wife Female 34 12/11/1984 CL-MF Elem. Grad. Brgy. Police Roman Catholic Member-4ps
Edongan, Trisha Mae Daughter Female 19 7/13/2000 S HS Grad. Roman Catholic
Edongan, Camila Daughter Female 18 9/11/2001 S HS Grad. Roman Catholic
Cruz, Jian Kyle Edongan Son Male 11 7/13/2008 Grade 6 Student Roman Catholic
Cruz, Margaret Edongan Daughter Female 9 7/29/2010 Grade 2 Student Roman Catholic
Cruz, Tristan Edongan Son Male 2 7/3/2017 Roman Catholic
Quiambao, Mike Andrew Maravella Brother in law Male 17 5/23/2002 Roman Catholic

Hinolan, Pricila Sistona Head Female 38 7/15/1981 CL-FF HS Grad. None 0955-593-5887 Roman Catholic None
Quiambao, Ma. Monica Maravella Wife Female 25 9/22/1994 CL-FF None OFW Roman Catholic
Hinolan, Mark Ivan Quiambao Son Male 6 8/1/2013 Grade 1 Student Roman Catholic

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities Electicity / Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) / Level II (Communal or Stand Posts)/ flowing Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking Yes / No Both
If no, where do you get your drinking water? POSO
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated / Yes No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type / Sanitary unsanitary None

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM
Barangay: 9 Primary Care Provider: BHS
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 27 yrs. Mobile Number or Email Address (optional):
Complete Address: Brgy. 9 Balayan, Batangas

Assessment of the Family, Home, and Environmental Conditions

A.      Members of the Family
Family Member Highest
(Surname, First Name, Middle Name) Sex Birthday Disability Educational Contact **NHIP
Family Position (Male, Female) Age (mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment Occupation Number Religion Membership

Quiambao, Moises Maravella Head Male 69 1/15/1950 M None None Roman Catholic None
Quiambao, Nenita Chavez Wife Female 59 2/18/1960 M None None Roman Catholic None

Quiambao, Abegail Chavez Head Female 36 4/13/1983 S HS Grad. OFW Roman Catholic Member-MW
Quiambao, Ian Son Male 16 10/7/2003 Grade 2 None Roman Catholic D-D
Cudiamat, Aldrey Quiambao Son Male 13 9/3/2006 Elem. Grad. None Roman Catholic D-D
Dimacali, Jhon Real Quiambao Son Male 4 9/25/2015
Dimacali, Jhon Jaquie Reigan Quiambao Daughter Female 5 9/10/2014 Day care Student Roman Catholic D-D
Dimacali, Jhon Biemon Quiambao Son Male 8 4/14/2011 Grade 3 Student Roman Catholic D-D
Dimacali, Jhon Paul Quiambao Son Male 7 5/22/2012 Grade2 Student Roman Catholic D-D

Qiambao, Anabelle Chavez Head Female 26 11/14/1993 S HS Grad. None Roman Catholic Member-NHT/4ps
Matin-Ao, Jussbelle Quiambao Daughter Female 7 1/13/2012 Grade 2 Student Roman Catholic 1-D
Matin-Ao, Saijan Louise Quiambao Son Male 5 11/24/2013 Kinder Student Roman Catholic 1-D

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female, FF for female-to-female)
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned Rented Others (spe____________________
b. Type of Construction Material: Light / Strong Mixed Others
c. Lighting Facilities / Electicity Kerosene Others (specify)

2.       Water Supply

a. Source Level I (Point Source) Level II (Communal or Stand Posts)/ flowing / Level III (Waterworks System or Individual House Connection)
b. Storage / None (direct from faucet) Covered container uncovered container
c. Used for Drinking / Yes No Both
If no, where do you get your drinking water?
3.       Waste Disposal
a.       Refuse and Garbage
i. Container Covered / uncovered
ii. Segregated Yes / No
iii. Method of Disposal
Hog Feeding Open Burning Open Dumping / Garbage Collection
Burial Fit Composting Others (spe____________________

b. Toilet Type Sanitary / unsanitary None

REMARKS: Age is conflict with the date of birth and incomplete details
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 30 yrs.
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Soreta, Teressa Alcomenda Head Female 50

Espinar, Anchinita Sistona Female 51
Soreta, Christian Jess Alcomenda Son Male 24
Soreta, John Mark Alcomenda Son Male 11

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

1/3/1969 CL-FF None

10/12/1967 CL-FF Elem. Grad.
12/25/1994 S Elem Grad.
7/27/2008 S Grade 5

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

Strong Mixed Others
Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

/ unsanitary None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Brgy. Police 9551596235 Roman Catholic None

Utility Roman Catholic None
None Roman Catholic None
Student Roman Catholic None

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 11 yrs.
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Vergara, Liberato Javier Head Male 57

Vergara, Maria Elena Alegre Wife Female 53
Vergara, Louella Jane A. Daughter Female 21
Vergara, Marielle Joy Alegre Daughter Female 19
Vergara, Albert John Alegre Son Male 19
Vergara, Justin Alegre Son Male 14
Vergara, Junelle Alegre Son Male 12

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

8/17/1962 Married O HS Grad.

7/20/1966 Married O College Graduate
4/27/1998 Single HS. Grad.
7/4/2000 Single HS. Grad.
7/4/2000 Single HS. Grad.
3/9/2005 Single Grade 9
11/22/2006 Single Grade 7

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

Strong Mixed Others
Kerosene / Others (specify) Rechargeable Li

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

/ Open Burning / Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Don Manuel LMBH

tions

Contact **NHIP
Occupation Number Religion Membership

Brgy. Tanod SDA Member

BWS Christian Member
None Roman Catholic None
TGP-Employee Roman Catholic ID
Student Roman Catholic ID
Student Roman Catholic ID
Student Roman Catholic ID

____________________

Others (specify) Rechargeable Light/Candle

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 1 Year
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Mendoza, Mark Anthony Credito Head Male 27

Soreta, Rossete Alcomenda Wife Female 26
Mendoza, Princess Tonette Soreta Daughter Female 8
Mendoza, Saint Anthony Soreta Son Male 5
Mendoza, Alyana Soreta Daughter Female 1

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

09/14/1992 CL-MF None

9/11/1992 CL-MF Elem. Grad.
04/24/2011 Single Grade 2
1/11/2013 Single None
1/5/2018 Single None

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

Strong Mixed Others
Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

/ unsanitary None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Tricycle Driver Roman Catholic None

None 9553845593 Roman Catholic None
Student Roman Catholic None
None Roman Catholic None
None Roman Catholic None

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 50 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Badillo, Rufino Atienza Head Male 60

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

7/4/1959 Single None

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: Dr. Laylo

tions

Contact **NHIP
Occupation Number Religion Membership

Maintenance Roman Catholic None

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 15 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Ermita, Apolonio Custodio Head Male 59

Tolentino, Carolina Liameto LIP F 43

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

9/2/1960 CL-MF None

9/8/1976 MF None

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Brgy. Health Center

tions

Contact **NHIP
Occupation Number Religion Membership

Sari-Sari Store 0975-498-8137 Roman Catholic Member-Voluntary

Sari-Sari Store Roman Catholic None

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 17 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Lerio, Jofferd Abanilla Husband Male 24

Lerio, Evangelyn Alicando Wife Female 23

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

08/23/1995 Married HS. Grad.

02/14/1996 Married HS. Grad.

male-to-male, MF for male-to-female, FF for female-to-female)

/ Rented Others (spe

Strong / Mixed Others
/ Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) / Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Trainer 9352186842 Roman Catholic Member

Housewife 9656171386 Jehova's Witnesses

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 11 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Sena, Noel Head Male 50

Ramos, Divina Wife Female 38
Sena, Dea Ramos Daughter Female 13
Sena, Joyce Ann Ramos Daughter Female 11
Sena, Jhon Carl ramos Son Male 8
Sena, Jhon Luis Ramos Son Male 6

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

9/7/1969 Married Elem. Grad.

8/2/1981 Married Elem. Grad.
02/28/2006 Grade 7
06/13/2008 Grade 5
6/6/2011 Grade 2
10/5/2013 Kinder

male-to-male, MF for male-to-female, FF for female-to-female)

/ Rented Others (spe

Strong / Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Mason INC Member-Indigent

None B.A. Member-4PS
Student B.A. D-Father
Student B.A. D-Father
Student B.A. D-Father
Student B.A. D-Father

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 4 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Hernandez, Roderick Dimailig Head Male 47

Rufa, Emerlyn Atienza Wife Female 37
Rufa, Ericka Mae Atienza Daughter Female 11
Hernandez, Angel Joy Rufa Daughter Female 5

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

11/7/1972 CL-MF HS. Grad.

01-28-192 CL-MF NONE
3/10/2008 Grade 6
10-27-2014 Daycare

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

Strong / Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Mason Roman Catholic None

NONE 9559443524 B.A. Member-Indigent
Student B.A.
Student B.A.

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 5 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Francisco, Gerald Delos Santos Head Male 29

Soreta, Leizl Alcomedes Wife Female 29
Francisco, Carlos Miguel Soreta Son Male 6
Francisco, Leslie Joy Soreta Daughter Female 4
Francisco, Ashley Jane Soreta Daughter Female 2

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

3/5/1990 CL-MF Elem. Grad.

4/10/1990 CL-MF Elem. Grad.
10/5/2013 Grade 1
2/8/2015
1/8/2017

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

Strong / Mixed Others
Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

/ unsanitary / None
 Primary Care Provider: DMLMDH

tions

Contact **NHIP
Occupation Number Religion Membership

Fruit Vendor Member-Voluntary

NONE Member-Voluntary
Student D-Mother
D-Mother
D-Mother

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Balasabas, Jayson Navaro Head Male 29

Balasabas, Rosechele Lasac Wife Female 27
Balasabas, Jayzel Son Male 7
Balasabas, Jayron Son Male 5
Balasabas, Jayronizel Son Male 2

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

1/9/1990 Married None

1/7/1992 Married Elem. Grad.
3/3/2012 Grade 1
3/1/2014 Grade 1
12-25-2016

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

Strong / Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: Brgy. Health Center

tions

Contact **NHIP
Occupation Number Religion Membership

Fisherman 9556788627 Roman Catholic Member-Voluntary

None Roman Catholic
Student Roman Catholic
Student Roman Catholic
Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 17 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Alicando, Alberto Garcia Father Male 54

Alicando, Aileen perez Mother Female 52
Alicando, Allan Perez Son Male 32
Alicando, Alfred Perez Son Male 26
Alicando, Bert Perez Son Male 15
Alicando, Totoy Perez Son Male 14
Alicando, Aiza Perez Daughter Female 12

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: Light
c. Lighting Facilities Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container / Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

12-15-1965 Married Elementary

12-16-1967 Married Elementary
8/11/1987 Single HS. Grad.
01-20-1993 Single Elementary
10-19-2004 Single Grade 8
5/10/2005 Single Grade 7
9/10/2007 Single Grade 7

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

Strong / Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Fisherman 9068149593 Jehova's Witnesses Member-Indigent

Housewife Roman Catholic D
Vendor Roman Catholic None
Carwash Boy 9974873799 Roman Catholic None
Student Jehova's Witnesses D
Student Jehova's Witnesses D
Student Jehova's Witnesses D

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 11 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Magyaya, Corazon Millar Head Female 52

Magyaya, Mark Aldren Millar Son Male 30
Magyaya, Mark Aries Millar Son Male 24
Magyaya, Mark Andrew Millar Father Male 28
Rufa, Pinky Rose LIP Female 23
Magyaya, Paul Andrie Rufa Son Male 6

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

20-22-1967 Widow Elem. Grad.

12/5/1989 Single HS. Grad.
01-20-1995 Single HS. Grad.
03-22-1991 CL-MF HS. Grad.
10-13-1996 CL-MF HS. Grad.
04-28-1993 Kinder

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Vendor 9972536154 Roman Catholic None

None Roman Catholic Member-Private
OFW Roman Catholic Member-MW
Vendor Roman Catholic Member
Watson's Saleslady Roman Catholic Member-Private
Student Roman Catholic D-D

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): Since 1990
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Delas Alas, Alberto Garcia Head Male 58

Delas Alas, Evangeline Domingo Wife Female 50
Delas Alas, Charles Domingo Son Male 24
Delas Alas, Jackielyn Domingo Daughter Female 28
Delas Alas, Janet Domingo Daughter Female 15
Delas Alas, Jhon Carlo Domingo Son Male 12
Domingo, Jocel Asuncion Niece Female 14
Delas Alas, Abigail Domingo Grand Daughter Female 3

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

10/11/1960 Married None

8/1/1969 Married HS. Grad.
02-15-1995 HS. Grad.
11-17-1991 Elem. Grad.
11/9/2004 Grade 8
10/8/2007 Grade 2
8/10/2008 Grade 2
06-26-2016

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Carpenter Roman Catholic Member-NHTS

Helper 9361868089 Roman Catholic ID
Poster-NAIA Roman Catholic Member-Private
Sales Lady Roman Catholic Member-Private
Student Roman Catholic ID
Student Roman Catholic ID
Student Roman Catholic
Roman Catholic D of Mother

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 49 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Soreta, Helen Bahia Head Female 69

Soreta, Jinggoy Grandson Male 20

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

07-20-1950 None
06-23-1999 None

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
/ Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Labandera Roman Catholic Member-SC

Construction Roman Catholic

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 25 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Calaud, Enrico Bagay Head Male 49

Calaud, Dolores Sistonia Wife Female 52
Calaud, Ricardo Sistonia Son Male 25
Calaud, Jerico Sistonia Son Male 23

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
/
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

11-24-69 Married None

09-18-1967 Married Elem. Grad.
10-20-1994 College. Grad.
12/4/1996 H.S. Grad.

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: Brgy. Health Center

tions

Contact **NHIP
Occupation Number Religion Membership

Grocery Store 9654655748 Roman Catholic Member-Voluntary

None Roman Catholic
Helper Emperador Roman Catholic
None Roman Catholic

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 43 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Dela Cruz, Charlie Head Male 64

Dela Cruz, Marita Soreta Wife Female 62

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

5/9/1955 Married B None

10/5/1957 Married A Elem. Grad.

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: Brgy. Health Center

tions

Contact **NHIP
Occupation Number Religion Membership

None Roman Catholic Member-SC

None 9362686917 Roman Catholic Member-SC

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 43 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Soreta, Eusebio Sistona Head Male 47

Mondragon, Gina Zebial Wife Female 43
Soreta, John Harvey Mondragon Son Male 8
Soreta, John Hardy Mondragon Son Male 7
Soreta, Hariett Mondragon Daughter Female 2

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source / Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

5/11/1971 CL-MF O Elem. Grad.

8/6/1976 CL-MF O Elem. Grad.
11/12/2010 Single Grade 2
08-19-12 Single
6/2/2017 Single

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Fisherman Roman Catholic Member-Indigent

Kasambahay Roman Catholic
Roman Catholic
Roman Catholic
Roman Catholic

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 26 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Vallestero, Rodolfo Delos Reyes Head Male 48

Vallestero, Jasmin Soreta Wife Female 43
Vallestero, Joyce Ann Soreta Daughter Female 20

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container / Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

02-23-71 Married Elem. Grad.

8/5/1976 Married None
03-21-1999 SHS Grad.

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) / Covered container
/ No
If no, where do you get your drinking water?
uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: RHU Balayan

tions

Contact **NHIP
Occupation Number Religion Membership

Tricycle Driver Roman Catholic None

Labandera Roman Catholic
Student Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 20 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Dalida, Daryll Jhon Cruzat Head Male 21

Adona, Maryjane Orence Wife Female 18
Dalida, Diana Divine Adona Daughter Female 5

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
/
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

07-31-1998 CL-MF College

12-27-2000 CL-MF Grade 12
12-16-2017

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: DMLMDH

tions

Contact **NHIP
Occupation Number Religion Membership

Student Roman Catholic None

Student Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 65 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Dalida, Reynaldo Nadong Father Male 68

Dalida, Germilininda Samiliano Wife Female 63
Dalida, Ryan Samiliano Son Male 33
Dalida, Davey Reynalyn 21
Dalida, Dave Jetro Son Male 18

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

01-29-1951 Married H.S. Grad.

01-17-1956 Married Elem. Grad.
12-18-1986
04-27-1998
10-23-2001 Grade 11

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: DMLMDH

tions

Contact **NHIP
Occupation Number Religion Membership

None BA Member SC
None BA Member SC
Security Roman Catholic Member-Private
Training BA D
Student Roman Catholic D

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 33 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Vedonia, Michael Samaniego Head Male 42

Vedonia, Jareme Dalida Wife Female 33
Vedonia, Zoe Michelle Dalida Daughter Female 7
Africa, Rachel Dalida Daughter Female 20

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container / Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

12/3/1976 Married College Grad.

10-13-1986 Married College Grad.
12-28-1911 Grade 2
10/12/1998 Grade 11

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: DMLMDH

tions

Contact **NHIP
Occupation Number Religion Membership

OFW Baptist
None 9166462183 Baptist Member-Private
Student Baptist D
Student Baptist D

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Sulit, Nida Ganti Head Female 61

Santos, Maricel Sulit Daughter Female 42

Santos, Vilmar Sulit Head Male 36

Hernandez, Gladys Cabral Wife Female 32
Santos, Mark Aron Hernandez Son Male 13
Santos, John Marwen Hernandez Son Male 11
Santos, Prince Ruzzel Hernandez Son Male 4

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

10/4/1958 W B None
01-27-1977 S None

12/7/1983 CL-MF B None

09-27-1987 CL-MF B None
09-20-2006 S B Grade 7
02-22-2008 S B Grade 5
08-15-2015 S B

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: Brgy. Health Center

tions

Contact **NHIP
Occupation Number Religion Membership

None Roman Catholic Member-SC

None Roman Catholic Dependent

Fisherman Roman Catholic Member-Indigent

None 9553924455 Roman Catholic Member-Indigent
Student Roman Catholic
Student Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 36 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Barquilla, Prescious Head Female 36

Barquilla, Donna Mae Daughter Female 18
Barquilla, Jhon Dave Son Male 16

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

3/8/1983 H.S. Grad.

7/8/2001 Grade 11
12/1/2003 Grade 1

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Brgy. Health Center

tions

Contact **NHIP
Occupation Number Religion Membership

None Roman Catholic Member-Voluntary

Student Roman Catholic
Student Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 19 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Balboa, Jay Ocampo Head Male 44

Balboa, Debbie Dalida Wife Female 42
Balboa, Javey Andrelyn Dalida Son Male 17
Balboa, Jade Dalida Daughter Female 11

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

01-24-1975 Married College Grad.

08-31-1976 Married College Grad.
9/7/2002 H.S. Grad.
09-29-2008 Grade 6

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: DMLMDH

tions

Contact **NHIP
Occupation Number Religion Membership

Nurse BA Member-Self Employed

Secretary BA Member-Private
Student BA D
Student BA D

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 1 Year
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Campado, Gideone Froyalde Head Male 50

Roxas, Gina Mendiola LIP Female 58

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

05-29-1969 CL-MF Elem. Grad.

7/2/1960 CL-MF None

male-to-male, MF for male-to-female, FF for female-to-female)

/ Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: DMLMDH

tions

Contact **NHIP
Occupation Number Religion Membership

Tricycle Driver Roman Catholic None

None 9362861307 Roman Catholic None

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 7 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Nocillas, Michael Simvilla Head Male 29

Soreta, Rachel Alcomendez Wife Female 31
Nocillas, John Michael Soreta Son Male 9
Nocillas, Steve Nash Soreta Son Male 6
Nocillas, Princess Shelly Soreta Daughter Female 4

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electicity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

05-13-1990 CL-MP None

02-13-1988 CL-MP Elem. Grad.
4/3/2010 Grade 11
4/4/2013 Grade 1
01-22-2018

male-to-male, MF for male-to-female, FF for female-to-female)

Rented / Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Vendor 9976798413 Roman Catholic Member-Voluntary

None Roman Catholic
Student Roman Catholic
Student Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 5 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Perez, Rene Bautista Head Male 44

Perez, Concepcion dalida Wife Female 48
Perez, Mikylla Dalida Daughter Female 14
Perez, Kayesalyn Dalida Daughter Female 12
Perez, Trishia Dalida Daughter Female 11
Perez, Rence Aron Dalida Son Male 10

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

11/11/1974 Married H.S. Grad.

8/12/1970 Married H.S. Grad.
10-26-2005 Grade 8
10/3/2007 Grade 6
7/5/2008 Grade 6
11-23-2009 Grade 4

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) / Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

/ unsanitary None
 Primary Care Provider: DMLMDH

tions

Contact **NHIP
Occupation Number Religion Membership

Carpenter BA Member-Voluntary
None 9555702459 BA D
Student BA D
Student BA D
Student BA D
Student BA D

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 1 Year
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Armada, Salvacion Levina Head Female 73

Armada, Arthuro JR. Levina Son Male 52

Armada, Joel Levina Head Male 48

Armada, Dezibeth Nicolas Wife Female 44
Armada, Judilyn Nicolas Daughter Female 23
Villarez, Sandie Gie Angela Nicolas Female 13

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

9/1/1946 Married None

04-24-1967 Single None

05-16-1971 Married Elem. Grad.

12-28-1974 Married None
12/11/1995 Single College Grad.
4/4/2006 Grade 8

male-to-male, MF for male-to-female, FF for female-to-female)

/ Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Don Manuel Lopez Hospital

tions

Contact **NHIP
Occupation Number Religion Membership

Maintenance BA Member-SC
Baker BA

Captain BA Member
B.H.W. BA Member
BA
Student BA

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 63 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Dalida, Nora Rodriguez Head Female 69

Dalida, Vhon Heindric Aquino Male 29

Dalida, Kelvin Aquino Male 27
Africa, Jhon Raven Dalida Male 25
Dalida, Andrea Llanzon Female 19
Dalida, Kristopher John Rodriguez Male 19

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

02-27-1950 W Elem. Grad.

1/9/1990 Elem. Grad.

11-14-1991 Elem. Grad.
10/9/1993 College Grad.
11-19-2000 H.S. Grad.
08-24-2000 / None

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: DMLMBH

tions

Contact **NHIP
Occupation Number Religion Membership

None Baptist Member-SC

None Roman Catholic

Labor Roman Catholic
Baptist
Freelancer Baptist

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 17 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

De Leon, Kristopher Head Male 34

De Leon, Aprilita Manalo Wife Female 31
De Leon, Harry Manalo Son Male 6
De Leon, Harley manalo Son Male 6

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

12/5/1985 Married O HS Grad.

3/4/1988 Married O HS Grad.
10-29-2016 Grade 1
10-29-2016 Grade 1

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Barangay Health Center

tions

Contact **NHIP
Occupation Number Religion Membership

Glassware Roman Catholic Member

None 9758518923 Roman Catholic
Student Roman Catholic
Student Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 45 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Dela Cruz, Roberto Soreta Head Male 45

De Leon, Liovina Akbang Wife Female 53
Dela Cruz Ronbert Caster Son Male 15

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

03-15-1976 CL-MF Elem. Grad.

03-13-1966 CL-MF Elem. Grad.
10/8/2004 Grade 8

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHC

tions

Contact **NHIP
Occupation Number Religion Membership

Municipal Employee Roman Catholic Member-Private

None Roman Catholic
Student Roman Catholic D-D

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Raagas, Jayson Espinilla Head Male 37

Raagas, Jay Ann Mondero Daughter F 11

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

04-14-1982 None
8/10/2008 Grade 5

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: DMLMDH

tions

Contact **NHIP
Occupation Number Religion Membership

Painter 90558115448 Roman Catholic Member-4PS

Student Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
/ Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Aldave, Angelito Gaa Head Male 48

Aldave, Alma Sena Wife Female 47
Aldave, David Jonathan Sena Son Male 26
Aldave, David Angelo Sena Son Male 18
Aldave, Hanna Jay Jay Micole Sena Daughter Female 21

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

4/10/1971 Married HS Grad.

6/5/1972 Married HS Grad.
08-31-1993 Single HS Grad.
03-14-2001 Single HS Grad.
09-29-1998 Single SHS Grad.

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

OFW Roman Catholic Member-MW

BAHW Roman Catholic D
Student Roman Catholic None
Student Roman Catholic None
Student Roman Catholic None

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 22 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Pornabe, Rose Divina Head Female 55

Castrojeres, Rodilyn Pornabe Daughter Female 25
Castrojeres, Alberto Pornabe Son Male 13
Castrojeres, Mikos Pornabe Son Male 16
Castrojeres, Moises Pornobe Son Male 21
Castrojeres, Roderico Pornobe Son male 33
Deleola, Maristel Amores Apo Female 16
Deleola, Glenn Apo Male 15

Castrojeres, Renato Pornobe Son Male 30

Castrojeres, Michelle Daughter in law Female
Castrojeres, Romeo Pornobe Anak Male 28
Ciervo, Reynabelle Daughter in law Female 21
Castrojeres, John Sedrick Ciervo Son Male 4

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source / Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
/ Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

03-16-1964 W None
11-28-1993 Single Hunchback None
5/12/2005 Single Grade 8
02-24-2003 Single Grade 10
07-14-1998 Single Elem Grad.
4/8/1986 Elem Grad.
5/2/2003 Single Grade 11
6/8/2004 Single Grade 9

02-26-1998 LIP HS Grad.

LIP
4/7/1991 LIP Elem. Grad.
06-25-1998 LIP Elem. Grad.
09-22-2015

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong / Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water? Poso
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Nanny 9067081720 Iglesia Sponsored Gov.

Housemaid Born Again Sponsored Gov.
Student Iglesia
Student Iglesia
Steel Man Iglesia Member-Private
Steel Man Iglesia Member-Private
Student Born Again
Student Iglesia

Steel Man Roman Catholic Member-Private

Waitress Roman Catholic
Tricycle Driver Roman Catholic Sponsorored Gov.
Waitress Roman Catholic Sponsored Gov.

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 25 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Dela Cruz, Cristobal Soreta Head Male 42

Dela Cruz, Janeth Zapata Wife Female 44
Dela Cruz, Jocris Zapata Son Male 23

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

12/7/1977 Married Elem. Grad

09-24-1975 Married Vocational
05-16-1996 Single HS Grad

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water? Gripo
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Mangingisda 9272932844 Roman Catholic Sponsored Gov.

None Roman Catholic Sponsored Gov.
None Roman Catholic Sponsored Gov.

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 20 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Dalida, Dexter Rodriguez Head Male 47

Delos Reyes, Antoniona Fwife Female 57
Dalida, Jeric Delos Reyes Son Male 19

Dalida, Joshua Ivan Delos Reyes Father Male 22

Sistona, Melanie Grego Wife Female 20
Dalida, Daniel Ivan Sistona Son Male 3

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
/ Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

10-20-1972 CL-MF Vocational

10/5/1962 CL-MF Elem Grad
04-29-2000

8/12/1997 CL-MF HS Grad

5/3/1999 CL-MF HS Grad
8/9/2019

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

OFW Roman Catholic Member-MW

None 9300011602 Roman Catholic None

None Roman Catholic Member-Not Active

SK Chairman Member
D-Mother

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 3 years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Aquino, George Cordero Head Male 56

Soreta, Allen Bahia LIP Female 43
Aquino, John Paul Soreta Son Male 3

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

04-13-1963 CL-MF HS Grad.

06-20-1976 CL-MF None
6/6/2016

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Welder 9360964847 Roman Catholic None

None Roman Catholic Member-Voluntary
Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Aldave, Gil Dela Torre Head Male 71

Aldave, Gloria Mortera Wife Female 71

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

7/7/1948 Married O None

3/8/1948 Married B None

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) / Covered container
/ No
If no, where do you get your drinking water? Poso
/ uncovered
/ No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

None Roman Catholic Member-SC

None 9953601969 Roman Catholic Member-SC

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 64 years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Balboa, Laura Sistona Head female 63

Senas, Christian Kurt Bascuguin Apo Male 4
Bascuguin, Amyluz Senas Mother Female 25

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

10-19-1954 W B Elem Grad.

10-15-2015
09-13-1995 SEP HS Grad.

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water? Gripo
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Don Manuel Lopez Hospital

tions

Contact **NHIP
Occupation Number Religion Membership

None 9055925935 Roman Catholic SC

Roman Catholic
OFW Roman Catholic Member-MW

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 10 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Balboa, Anthony Sistona Head Male 44

Garcia, Shirley Tandingan Wife Female 35
Balboa, Robert Garcia Son Male 8
Balboa Nathalie Garcia Daughter Female 6
Camasora, Jhobert Son Male 17

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

06-13-1975 CL-MF Elem Grad.

8/4/1984 CL-MF HS Grad.
01-29-2011 Grade 2
07-26-2013 None
4/1/2002 Grade 6

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Balayan RHU

tions

Contact **NHIP
Occupation Number Religion Membership

Painter Roman Catholic Member-Indigent

Utility Roman Catholic None
Student Roman Catholic I-D
Roman Catholic I-D
Painter Roman Catholic I-D

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 7 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Balboa, Eric Sistona Head Male 35

Lacaden, Carla Mae Atienza Wife Female 24

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

08-13-1984 CL-MF Elem Grad

02-20-1995 CL-MF Elem Grad

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water? Gripo
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Painter Roman Catholic None

Roman Catholic None

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Balboa, Victor Sistona Head Male 46

Baergado, Maricel De Guzman Wife Female 32

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

07-23-1973 CL None
12/3/1987 CL Elem. Grad.

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) / Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary / None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Fisherman Roman Catholic Member Indigent

Labandera 9366630995 Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Ramirez, Federico Guardian Head Male 51

Ramirez, Marites Guardian Wife Female 53
Ramirez, Jomar Guardian Son Male 31
Ramirez, Jemalyn Guardian Daughter Female 30
Ramirez, Jaymark Guardian Son Male 28
Ramirez, Jude Mark Guardian Son Male 23
Ramirez, John Martin Guardian Son male 17

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

04-30-1968 Married HS Grad.

11-23-1965 Married HS Grad.
12-30-1987 Single College
8/2/1989 Single College
03-13-1991 Single College
10/2/1996 Single College
06-15-2002 Single Grade 12

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water? Mineral Water
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Balayan RHU

tions

Contact **NHIP
Occupation Number Religion Membership

Mini Bakery 9357542031 Jehovah's Witnesses None

Vendor Jehovah's Witnesses 4PS
9107455654 Roman Catholic Member-Private
Call Center 9358641900 Roman Catholic Member-Private
Receptionist 9050710339 Roman Catholic Member-Private
Technician 9361550531 Roman Catholic Member-Private
Student 9059615937 Roman Catholic Member-Private

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
r? Mineral Water
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Sistona, Litercia Grego Head Female 50

Sistona, Marlon Grego Son Male 24
Sistona, Mylene Grego Daughter Female 26
Sistona, Shin Lorraine Grandaughter Female 9

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

1/10/1969 LIP-MF None

10-22-1994 Single HS. Grad.
3/5/1993 SEP HS. Grad.
12-30-2011

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water? Mineral Water
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Housemaid 9055818120 Roman Catholic Member-Voluntary

Line Man Roman Catholic
None Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
r? Mineral Water
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
10 years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Cervas, Nickson Sebastian Head Male 42

Cervas, Laila Bagay Wife Female 39
Cervas, Ashley Nicole Cervas Daughter Female 14

Bagay, Marvin Baller Brother Male 38

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

01-19-1976 Married HS Grad

10-27-1979 Married HS Grad
08-18-2005 Grade 9

7/12/1981 Single None

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Dr. Laylo

tions

Contact **NHIP
Occupation Number Religion Membership

Security Roman Catholic Member-Private

Security 9098457810 BA Member-Private
Student BA

BA

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 2 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Roxas, Enrico Pantoja Head Male 53

Roxas, Elsie Arguileta Wife Female 56
Roxas, Mark Lester Arguileta Son Male 33
Roxas, Mae Leslie Arguileta Daughter Female 30
Roxas, Maria Lyncel Arguileta Daughter Female 26
Santos, Keishena mae Roxas Apo Female 8
Mangubat, Don Roxas Apo Male 5
Santos, Khelie Mae Roxas Apo Female 10

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

08-20-1966 Married Elem Grad.

11/2/1963 Married College
03-23-1986 Single HS Grad.
06-30-1989 M/SEP HS Grad.
4/8/1992 Single HS Grad.
10/8/2011 Single Grade 3
07-24-2014 Single Kinder
10-30-2009 Single Grade 5

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water? Mineral
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Balayan RHU

tions

Contact **NHIP
Occupation Number Religion Membership

Fisherman Roman Catholic D

None 9450866267 Roman Catholic Member-Voluntary
Dizer Roman Catholic Member-Private
OFW Roman Catholic Member-MW
Student Roman Catholic Member-MW
Student Roman Catholic D-Mae Leslie
Student Roman Catholic D-Mae Leslie
Student Roman Catholic D-Mae Leslie

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Cruz, Nestor Gloria Head Male 60

Edongan, Mary Ann quiambao Wife Female 34
Edongan, Trisha Mae Daughter Female 19
Edongan, Camila Daughter Female 18
Cruz, Jian Kyle Edongan Son Female 11
Cruz, Margaret Edongan Daughter Male 9
Cruz, Tristan Edongan Son Male 2
Quiambao, Mike Andrew Maravella Brother in law Male 17

Hinolan, priscila Sistona Head Female 38

Quiambao, Ma. Monica Maravella Wife Female 25
Hinolan, Mark ivan Quiambao Son Male 6

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

7/4/1959 CL-MF Elem Grad

11/12/1984 CL-MF Elem Grad
07-13-2000 Single HS Grad
11/9/2001 Single HS Grad
07-13-2008 Single Grade 6
07-29-2010 Single Grade 2
3/7/2017 Single
05-23-2002 Single

07-15-1981 CL-FF HS Grad

09-22-1994 CL-FF None
1/8/2013 Single Grade 1

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
/ Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water? Poso
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider:

tions

Contact **NHIP
Occupation Number Religion Membership

Painter Roman Catholic

Brgy. Police Roman Catholic Member-4PS
Student Roman Catholic
Student Roman Catholic
Student Roman Catholic
Student Roman Catholic
Roman Catholic

Roman Catholic None

None 9555935887 Roman Catholic
OFW Roman Catholic
Student

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Balboa, Roger Sistona Head Male 40

Balboa, Emilian Ramirez Wife Female 39
Balboa, Tracy Ramirez Daughter Female 16
Balboa, Mark railey Ramirez Son Male 15
Balboa, Cyril Mae Ramirez Daughter Female 13
Balboa, Ronian Ramirez Son Male 11

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

7/4/1959 Married
11/9/1980 Married
10-15-2003 Single
09-25-2004 Single
9/5/2006 Single
04-20-2008 Single

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider:

tions

Contact **NHIP
Occupation Number Religion Membership

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 39 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Baqui, Anselmo Panganiban Head Male 59

Baqui, Carmelita Badillo Wife Female 54

Baqui, Elmo Jun Badillo Father Male 25

Baqui, Jennifer Dastas Wife Female 25
Baqui, Lara Mae Dastas Daugther Female 5

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

04-21-1960 Married Elem Grad

8-23-1964 Married Elem Grad

03-25-1994 Married Elem Grad

08-17-1994 Married HS Grad
10-17-2014 Single Daycare

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water? Poso
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Dr. Laylo

tions

Contact **NHIP
Occupation Number Religion Membership

Brgy. Kagawad Roman Catholic Member-Indigent

None 9169960673 Roman Catholic I-D

Trucking/Pahinante Roman Catholic None

BHW Roman Catholic None
Roman Catholic None

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 9 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Baque, Augusto Badillo Head Male 38

Baque, Kristine Arellano Wife Female 35
Baque, Ryan Jay Arellano Son Male 14
Baque, Princess Joy Arellano Daughter Female 9
Baque, John Ray Arellano Son Male 4

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

12/8/1981 Married None

09-23-1984 Married HS Grad
11/6/2005 Single Grade 9
8/5/2010 Single Grade 3
11-14-2018 Single

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water? Poso
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Dr. Laylo

tions

Contact **NHIP
Occupation Number Religion Membership

Driver Roman Catholic Member-Voluntary

None 93756580310 Roman Catholic D-D
Student Roman Catholic D-D
Student Roman Catholic D-D

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 36 years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Baque, Maximiano Panganiban Head Male 66

Martos, Prisula Sistona LIP Female 62

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

04-21-1953 CL O None
10/2/1957 CL None

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) / Covered container
No
If no, where do you get your drinking water? Poso
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Brgy. Tanod Roman Catholic Member-Sponsored

None Roman Catholic Member-Sponsored

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 2 years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Magnaye, Reynaldo Discalles Head Male 43

Magnaye, Josephine Magsino Wife Female 40
Magnaye, Ron Joseph Son Male 22
Magnaye, Reynaldo Jr. Son Male 19
Magnaye, Jhon Carlo Son Male 15
Magnaye, Michael Angelo Son Male 11
Magnaye, Princess Daughter Female 9
Magnaye, Patricia Mae Daughter Female 7
Magnaye, Mark jay Son Male 2

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

02-17-1976 Married None

02-20-1979 Married None
02-20-1997 Single None
11-30-2000 Single None
3/1/2004 Single Grade 5
2/11/2007 Single Grade 3
12-29-2009 Single Grade 3
09-28-2012 Single Grade 1
5/8/2017 Single

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) / Covered container
/ No
If no, where do you get your drinking water? Poso
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Tricycle Driver 9368150512 Roman Catholic Member-Sponsored

None Roman Catholic
Tricycle Driver Roman Catholic
Cook Roman Catholic
Student Roman Catholic
Student Roman Catholic
Student Roman Catholic
Student Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 35 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Manoquial, Andy Sarmiento Head Male 44

Manoquial, Erica Baque Wife Female 35
Manoquial, Janice Baque Daughter Female 18
Manoguial, John Mackedrl Son Male 16
Manoguial, Ayne Joie Baque Daughter Female 13
Manoguial, Andrew Baque Son Male 8

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source / Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

08-21-1975 Married O College Grad.

10/3/1984 Married AB Elem Grad.
01-23-2001 Single SHS Grad
04-28-2003 Single Grade 11
12-17-2005 Single Grade 9
8/1/2011 Single Grade 8

male-to-male, MF for male-to-female, FF for female-to-female)

/ Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) / Covered container
/ No
If no, where do you get your drinking water? Mineral Water
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: Brgy. Health Center

tions

Contact **NHIP
Occupation Number Religion Membership

Tricycle Driver 9658850204 Roman Catholic Member-Voluntary

None Roman Catholic
Tindera Roman Catholic
Student Roman Catholic
Student Roman Catholic
Student Roman Catholic

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
r? Mineral Water
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 35 Years
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Magsino, Ramilito Pallet Head Male 46

Magsino, Maxima Samonte Wife Female 43
Magsino, Emilito Samonte Son Male 25
Magsino, Romenick Samonte Son Male 23
Magsino, Ramilyn Samonte Daughter Female 20
Magsino, Rhamiel Samonte Son Male 10

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage None (direct from faucet)
c. Used for Drinking / Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container / Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

08-19-1973 Married Elem Grad

05-29-1976 Married Elem Grad
09-16-1994 LIP HS Grad
7/2/1996 LIP HS Grad
05-19-1999 Single HS Grad
1/2/2009 Single Grade 5

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) / Covered container
No
If no, where do you get your drinking water?
uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: BHS

tions

Contact **NHIP
Occupation Number Religion Membership

Tricycle Driver 9976135895 BA Member-Brgy

Vendor BA
Security Barangay BA
Fabric BA
Singer BA
Student BA

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.):
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Dela Cruz, Raymart Castor Head Male 28

Burato, Bonalyn Gayos Wife Female 30
Dela Cruz, Rhian Burato Daughter Female 7
Dela Cruz, Rhiana Burato Daughter Female 1

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

8/1/1991 CL-MF Elem Grad

05-29-1989 CL-MF Elem Grad
02-16-2012 Grade 2
12-30-2017

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) / Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water? Mineral
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: B-9 BHW

tions

Contact **NHIP
Occupation Number Religion Membership

Security Roman Catholic Member-Indigent

None Roman Catholic Member-Voluntary
Student Roman Catholic

____________________

Others (specify)

Level III (Waterworks System or Individual House Connection)

uncovered container
Both
r? Mineral
Open Dumping / Garbage Collection
____________________
Barangay: 9
Purok: 2
Residence: / Permanent Present
Length of Residency (in yrs./mos.): 2 months
Complete Address: Brgy. 9 Balayan, Batangas

Asses
A.      Members of the Family
Family Member
(Surname, First Name, Middle Name) Sex
Family Position (Male, Female) Age

Badillo, Rufino Atienza Head Male 60

*S-single, M-married, W-widow/er, Sep-separated, CL-common law (MM for male-to-male, MF for male-to-female
**NHIP Membership - write direct, indirect, dependent, or non-member

A.      Home and Environment

1.       Home
a. Ownership: / Owned
b. Type of Construction Material: / Light
c. Lighting Facilities / Electricity

2.       Water Supply

a. Source Level I (Point Source)
b. Storage / None (direct from faucet)
c. Used for Drinking Yes

3.       Waste Disposal

 a.       Refuse and Garbage
i. Container Covered
ii. Segregated / Yes
iii. Method of Disposal
Hog Feeding
Burial Fit

b. Toilet Type / Sanitary

REMARKS: Age is conflict with the date of birth and incomplete details
 FAMILY PROFILING FORM

Mobile Number or Email Address (optional):

Assessment of the Family, Home, and Environmental Conditions

Highest
Birthday Disability Educational
(mm/dd/yyyy) *Marital Status Blood Type (if PWD, specify) Attainment

7/4/1959 Single None

male-to-male, MF for male-to-female, FF for female-to-female)

Rented Others (spe

/ Strong Mixed Others
Kerosene Others (specify)

nt Source) Level II (Communal or Stand Posts)/ flowing

ct from faucet) Covered container
/ No
If no, where do you get your drinking water?
/ uncovered
No

Open Burning Open Dumping

Composting Others (spe

unsanitary None
 Primary Care Provider: B-9 Health Center

tions

Contact **NHIP
Occupation Number Religion Membership

Maintenance Roman Catholic None

____________________

Others (specify)

/ Level III (Waterworks System or Individual House Connection)

uncovered container
Both
Open Dumping / Garbage Collection
____________________