DOCUMENT

1. Republic of the Philippines
Department of Education
Region III
Division of Nueva Ecija
District of General Tinio
GREEN LAND ELEMENTARY SCHOOL
H O M E V I S I T R E C O R D S
I. Pupils Personal Status
1. Name: _________________________________ Nickname:_______________ Sex:______ Grade: __________
2. Place of Birth: ___________________________________________________Birthday:___________________
3. Address:________________________________________________________Nationality:_________________
4. Type of Community:_________________________________________________________________________
II. Family Status
1. Father:__________________________________Age:______________Occupation:_______________________
Salary:__________________Educ’l Attainment:___________________Religion:_________________________
2. Mother:_________________________________Age:______________Occupation:_______________________
Salary:__________________Educ’l Attainment:___________________Religion:_________________________
3. Guardian:_______________________________Age:_______________Occupation:______________________
Salary:__________________Educ’l Attainment:___________________Religion:_________________________
4. No. of children in the family:__________________Brother/s:_________________Sister/s:_________________
Position of the child in the family:_______________________________________________________________
Relatives living in the house:___________________________________________________________________
5. Education of brother/s, sister/s and relatives in the family:
Name Relationship Age Educ’l Attainment Occupation
______________________________ __________ __________ _______________ ______________
______________________________ __________ __________ _______________ ______________
______________________________ __________ __________ _______________ ______________
______________________________ __________ __________ _______________ ______________
______________________________ __________ __________ _______________ ______________
*Language spoken at home:______________________________________________________________________
6. Economic Status
a. Excellent;_______________Good:_______________Moderate:________________Poor:_______________
b. House owned or rented?________________________ How much is the rental?_______________________
c. Type of family dwelling(barong-barong, house, apartment)_______________________________________
d. Facilities available: toilet:_____ bath:_____ light:_____ running water:_____
Television: _____ home library: _____ computer set/laptop: _____
e. House is built of (concrete, wood, bamboo):___________________________________________________
7. Food production activities:____________________________________________________________________
8. Kind of fence(none, bamboo, concrete, plants):____________________________________________________
9. How many animals are kept(loose, tied in a barn):__________________________________________________
10. Disposal of garbage (plastic, can, pit):____________________________________________________________
11. Recommendation:___________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________.
________________________________________
Signature of Guardian
________________________________________
Interviewer

2. Republic of the Philippines
Department of Education
Region III
Division of Nueva Ecija
District of General Tinio
GREEN LAND ELEMENTARY SCHOOL
Guidance Service Office
L I H A M P A A N Y A Y A
____________________
Petsa
______________________________
______________________________
______________________________
Mahal na G./Gng./Bb.___________________________________
Magalang pong ipinababatid na ang inyong anak o inaalagaang mag-aaral na si
______________________________ na kasalukuyang nasa Baitang __________Pangkat__________ ay
nagkaroon ng suliranin sa kanyang pag-aaral, kung kaya’t inaanyayahan po kayong magtungo sa Guidance
Office sa araw ng ____________________ petsang ______________________________ upang mapag-usapan
sa paaralan ang suliraning nabanggit.
Inaasahan po ang maagap ninyong pagtugon.
Gumagalang,
_________________________________________
Guidance Councilor/Coordinator
_________________________________________
Pirma ng tumanggap ng paanyaya
Petsa:___________________

3. Republic of the Philippines
Department of Education
Region III
Division of Nueva Ecija
District of General Tinio
GREEN LAND ELEMENTARY SCHOOL
A N E C D O T A L R E C O R D
Name of Pupil:______________________________________________School:_________________________________
Grade and Section:___________________________________________Date:___________________________________
INCIDENT:
______________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
TEACHER ACTION:
______________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________

4. Republic of the Philippines
Department of Education
Region III
Division of Nueva Ecija
District of General Tinio
GREEN LAND ELEMENTARY SCHOOL
Guidance Services Office
A U T H O R I T Y T O T R A V E L
For Home Visitation
___________________________________
___________________________________
___________________________________
___________________________________
You are hereby authorized to conduct home visitation at ___________________________________ on
_________________________ to discuss ________________________________________ with the
parents/ guardian of _______________________________________ a Grade __________ Section
__________ this School Year 20_____-20_____
Your travel is on official time and it is advised that necessary precaution and safety during your travel
is highly recommended.
__________________________________________
Signature of the School Head/District Supervisor
Over Printed Name

5. Republic of the Philippines
Department of Education
Region III
Division of Nueva Ecija
District of General Tinio
GREEN LAND ELEMENTARY SCHOOL
C A S E S T U D Y
I. PERSONAL DATA
a. Name of Pupil:______________________________________________________________________
b. School:____________________________________________________________________________
c. Home Address:______________________________________________________________________
d. Date of Birth:_______________________________________________________________________
e. Grade and Section:___________________________________________________________________
f. Age:______________________________________________________________________________
II. FAMILY BACKGROUND
a. Name of Father:_____________________________________________________________________________
b. Educ’l Attainment:___________________________________________________________________________
c. Socio-Economic level:________________________________________________________________________
d. Language spoken at home:_____________________________________________________________________
e. National Status of Parents;_____________________________________________________________________
f. Living with step-mother:______________________________________________________________________
g. Pupil live in other home:______________________________________________________________________
h. Number in the Family:________________________________________________________________________
i. Order of Birth;______________________________________________________________________________
The problem; Family Problem/Neglected of Parents
______________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________
Referred by Teacher:_________________________________________________________________________________
Attitude toward School:______________________________________________________________________________
Attitude toward Classmates:___________________________________________________________________________
Attendance:________________________________________________________________________________________