Pre-Electrification Socioeconomic Survey Form
Basic Information
Name of Household Head
Contact Number
Address
Barangay
Municipality
Province
Household Profile
Number of Family Members
Number of Children (0-17 yrs)
Number of Elderly (60+ yrs)
Socioeconomic Information
Main Source of Income
Estimated Monthly Income
Other Livelihood/Occupation
Current Energy Use
Current Main Lighting Source
Kerosene Lamp
Battery Lamp
Candle
Solar/Other
How much do you spend monthly for lighting?
Do you use any alternative energy source?
Willingness to Electrify
Are you willing to be connected to the grid?
Yes
No
Not Sure
If yes, what appliances/equipment do you plan to use? (list)
Surveyor's Information
Name of Surveyor
Date of Survey