Republic of the Philippines
OFFICE OF THE
SANGGUNIANG KABATAAN
Barangay 43-A, Tacloban City
KATIPUNAN NG KABATAAN PROFILE
TO THE RESPPONDENT:
Good day!
We are currently conducting a study that focuses on assessing the demographic information of the Katipunan ng Kabataan.
The said data gathering also aim to come up with relevant interventions through programs and projects based on the
profiles of the youth in the area and identified issues and recommendations. We would like to ask your participation by
taking your time to answer this questionnaire. Please read the questions carefully and answer them accurately.
RESER ASSURED THAT THAT THE INFORMATION GATHERED FROM THIS STUDY WILL BE TREATED
WITH UTMOST CONFIDENTIALITY.
PLEASE FILL OUT THIS FORM CORRECTY.
Personal Information
ID No.:
Name
Last Name
First Name
Age
Civil Status
Sex
Contact No:
Registered SK -Voter
Single
Male
Female
Yes
No
Highest Educational
Attainment :
Elementary
College
Birthdate:
Married
Religion
Email Address
Registered National Voter
Junior HS
Vocational
Course:
In School
If Out-of-School kindly state the
reason
If working
Government
Middle Name
Out-of-School
Private
Others Please Specify:
Yes
No
Senior HS
Post-Graduate
ALS
Doctorate
Employed
Unemployed
Self-Employed
If Government, what particular ageny?
OTHER INFORMATION
Do you have disability/ies?
No
If Yes, please specify:
Do you have medical condition/s?
No
If Yes, please specify:
Are you a member of any Organization/s ?
If yes, please specify what organization/s :
Ext. Jr/Sr
Duration:
Skills:
Interests:
What Activities would you like suggest to our
SK Council?
On what particular concern would you like the
SK Council to help?
What are your expectations for our new set of
SK Council?
I hereby give my consent to the Sangguniang Kabataan of Brgy. 43-A , Quarry District,
Tacloban City to collect, process, use and store all the information I have provided herein for
the purpose of profiling Katipunan ng Kabataan (KK) of Brgy. 43-A and other legitimate
purposes pursuant to Republic Act No. 10472 also known as Sangguniang Kabataan Reform
Act of 2015, Republic Act No. 10173 also known as Data Privacy Act of 2012 and other
statutory acts that may apply.
Do note that the SK cannot utilize any information herein as evidence as evidence in any
legal proceedings.
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Signature Over Printed Name
Date