Annex B Livelihood Survey Questionnaire Individual

ANNEX B
Republic of the Philippines

Department of Labor and Employment
SURVEY QUESTIONNAIRE FOR INDIVIDUAL PROJECTS ASSISTED UNDER THE DOLE INTEGRATED LIVELIHOOD PROGRAM
ID No. Region: ________ Province: ___________________ City/Municipality: __________________
Instructions: Please write legibly and submit the accomplished form to the DOLE Regional/Provincial/Field Livelihood Focal
Person. The questionnaire should be accomplished by the beneficiary of individual project.
I. Beneficiary Profile
1. Name of Beneficiary:
Given Name Middle Name Surname
2. Sex: Male Female 3. Contact No.: 4. Email Address:
5. Highest Educational Attainment: Elementary Secondary Vocational College Post Graduate

6. Type of Members:
Self-employed with insufficient income Farmers Elderly Workers Sugar Workers
Low/minimum wage earners Fisherfolks Former Rebel Others, please
Displaced Workers Women Victims of Armed Conflict specify:* ______
Seasonal Workers Working Youth Family Members/dependents
Parents/Guardians of Child Laborers Indigenous People of Probationers/Parolees
Family Members/dependents of Person with Disability Exited 4Ps Beneficiaries
II. Project Profile
7. Name of Project:
8. Project Location:
House No. /Street/Subdivision Barangay Municipality/City Province
9. Nature of Project:
Service Related Agriculture Related Retailing Manufacturing/ Production
Automotive and Repair Shop Fishery Related Food Vending Related
Beauty Parlor/Barbershop Gardening Nego-Kart Breads & Pastry/Baking
Canteen and Catering Services Livestock (i.e Hog Raising) Rice Retailing Dress/Garments Making
Carpentry Welding Poultry Farming Sari-sari Store Food Processing
Carwash Vulcanizing Rice Farming Tricycle Spare Furniture Making
C
Computer/Printing Services Vegetable/Crop farming Parts Retailing Jewelries/Accessories
a Massage Services Making
r Small Transport Services Handicrafts
e Others, please specify: ________________________
10.b Program Component: 11. Mode of Implementation
d Formation Enhancement Restoration Direct Administration Through ACP, specify* ___________________
e o
12. Amount Grantedo by DOLE: ₱_______________
o 13. Date Awarded: 14. Date the Project Started:
r u
u
15. Other Support Services Receivedu from DOLE: ________________________ p
p p
16. New Skills, and Knowledge Acquired during the Project Implementation, please specify: *_____________________________
III. Project Status
17. Project Status After 2 Years of Grant: Operational Stopped Operation, when __________________
18. If Operational, Challenges/Issues/Concerns (Please refer to the list at the back):
19. If Stopped Operation, specify the reason (Please refer to the list at the back):
IV. Financial Status

20. Estimated Monthly Net Income Before the Availment of DOLE’s Livelihood Assistance
₱0 ₱11,001-₱13,000 ₱25,001-₱27,000 ₱39,001-₱41,000
₱1,000 and below ₱13,001-₱15,000 ₱27,001-₱29,000 ₱41,001-₱43,000
o ₱1,001-₱3,000 o ₱15,001-₱17,000 o ₱29,001-₱31,000 ₱43,001-₱45,000
u ₱3,001-₱5,000 u ₱17,001-₱19,000 u ₱31,001-₱33,000 ₱45,001-₱47,000
p p p
₱5,001-₱7,000 ₱19,001-₱21,000 ₱33,001-₱35,000 ₱47,001-₱50,000
o ₱7,001-₱9,000 o ₱21,001-₱23,000 o ₱35,001-₱37,000 more than ₱50,000, please specify: * ___________
u ₱9,001-₱11,000 u ₱23,001-₱25,000 u ₱37,001-₱39,000
p p p
21. Estimated Monthly Net Income Two (2) years After Availment of DOLE Assistance
₱0 ₱11,001-₱13,000 ₱25,001-₱27,000 ₱39,001-₱41,000
₱1,000 and below ₱13,001-₱15,000 ₱27,001-₱29,000 ₱41,001-₱43,000
o ₱1,001-₱3,000 o ₱15,001-₱17,000 o ₱29,001-₱31,000 ₱43,001-₱45,000
u ₱3,001-₱5,000 u ₱17,001-₱19,000 u ₱31,001-₱33,000 ₱45,001-₱47,000
p p p
₱5,001-₱7,000 ₱19,001-₱21,000 ₱33,001-₱35,000 ₱47,001-₱50,000
o ₱7,001-₱9,000 o ₱21,001-₱23,000 o ₱35,001-₱37,000 more than ₱50,000, please specify: * __________
u ₱9,001-₱11,000 u ₱23,001-₱25,000 u ₱37,001-₱39,000
p p p
22. Working Capital at the start of the project
₱30,000 and below ₱300,001-₱330,000 ₱600,001-₱630,000 ₱900,001-₱930,000
₱30,001-₱60,000 ₱330,001-₱360,000 ₱630,001-₱660,000 ₱930,001-₱960,000
o ₱60,001-₱90,000 o ₱360,001-₱390,000 o ₱660,001-₱690,000 ₱960,001-₱990,000
u ₱90,001-₱120,000 u ₱390,001-₱420,000 u ₱690,001-₱720,000 ₱990,001-₱1,020,000
p p p
₱120,001-₱150,000 ₱420,001-₱450,000 ₱720,001-₱750,000 ₱1,020,001-₱1,050,000
o ₱150,001-₱180,000 o ₱450,001-₱480,000 o ₱750,001-₱780,000 more than ₱1,050,000, please
u ₱180,001-₱210,000 u₱480,001-₱510,000 u ₱780,001-₱810,000 specify: * _____________
p p p
₱210,001-₱240,000 ₱510,001-₱540,000 ₱810,001-₱840,000
₱240,001-₱270,000 ₱540,001-₱570,000 ₱840,001-₱870,000
₱270,001-₱300,000 ₱570,001-₱600,000 ₱870,001-₱900,000
23. Working Capital of the project after two (2) years of grant
₱30,000 and below ₱300,001-₱330,000 ₱600,001-₱630,000 ₱900,001-₱930,000
₱30,001-₱60,000 ₱330,001-₱360,000 ₱630,001-₱660,000 ₱930,001-₱960,000
o ₱60,001-₱90,000 o ₱360,001-₱390,000 o ₱660,001-₱690,000 ₱960,001-₱990,000
u ₱90,001-₱120,000 u ₱390,001-₱420,000 u ₱690,001-₱720,000 ₱990,001-₱1,020,000
p p p
₱120,001-₱150,000 ₱420,001-₱450,000 ₱720,001-₱750,000 ₱1,020,001-₱1,050,000
o ₱150,001-₱180,000 o ₱450,001-₱480,000 o ₱750,001-₱780,000 more than ₱1,050,000, please
u ₱180,001-₱210,000 u₱480,001-₱510,000 u ₱780,001-₱810,000 specify: * _____________
p p p
₱210,001-₱240,000 ₱510,001-₱540,000 ₱810,001-₱840,000
₱240,001-₱270,000 ₱540,001-₱570,000 ₱840,001-₱870,000
₱270,001-₱300,000 ₱570,001-₱600,000 ₱870,001-₱900,000
V. Project Milestone
24. Citation/Awards/Recognition Received by the Project:
25. Business Expansion of the project:
26. Registration/Licenses/Permits Issued i.e. DTI, FDA, BIR, SEC, CDA, etc.:
27.1. No. of Workers employed in the project: 27.2 No. of Female workers employed in the project:
VI. Other Sponsoring Agency/Organization
28.1 Name of Agency Organization: (LGU, DTI, DSWD, DA, DAR, 28.2 Support Services/Assistance Received:
TESDA, DOST, etc. private institutions):
VII. Signatories
29.1 Name of Respondent: 29.2. Signature: 29.3. Date:
30.1. Name of Interviewer: 30.2. Signature: 30.3. Date:
I hereby certify that the information provided are true and

correct based on the interview conducted with the beneficiaries:
*- Need to be filled-up once selected

List of Issues/Support Services Needed
Marketing Aspect: Production Aspect:

A1 -Lack of market for the product/service P1 -Limited resources such as raw materials, labor, equipment
A2 -Needs improvement in the quality of product/service P2 -High production costs and wastages
A3 -Needs improvement in the packaging and labeling of P3 -Proper food handling and sanitation
product/service P4 -Low level of productivity
A4 -FDA approval of product/service P5 -Safety in the workplace
A5 -Poor condition of farm-to-market roads P6 -Low level of productivity-technology
A6 - Increasing no. of competitors P7-Defected Machines/Tools/Equipment
A7- Seasonal product/services P8-Facility/Building Location
A8-Access to the Internet/Technology P0 -Others (please specify)
A0-Others (please specify)
Management Aspect: Financial Aspect:

M1 -Lack of written policies, standards, rules and regulations F1 -Low access to credit
for the project implementation (i.e. profit sharing scheme, F2 -No or limited knowledge in preparation of financial
by laws, etc) statements
M2 -No Project Management Team F3 -Lack of standard record-keeping system
M3 -Non-functional Project Management Team F4-Depleted capital
M4 -Lack of capacity to access technical and capital assistance F5-Credits/bad debts
from other government agencies or private institutions F6-Lack of Cash Flow
M5-Lack of training F7-Taxes and Government Compliance
M6-Poor management F8-Emergency Expenses
M7-Put up New Business FO -Others (please specify)
M8-Resitance to Change
MO -Others (please specify)

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ANNEX B

Republic of the Philippines

5. Highest Educational Attainment: Elementary Secondary Vocational College Post Graduate

18. If Operational, Challenges/Issues/Concerns (Please refer to the list at the back):

IV. Financial Status

30.1. Name of Interviewer: 30.2. Signature: 30.3. Date:

I hereby certify that the information provided are true and

*- Need to be filled-up once selected

Marketing Aspect: Production Aspect:

Management Aspect: Financial Aspect:

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