Books Issued and Returned

8/12/2019 Books Issued and Returned

1/31

School ID School Year

Name of School

2 3 4 5 6 9 10 11 12 13 16 17 18 19 20 23 24 25 26 27 30

M T W TH F M T W TH F M T W TH F M T W TH F M

Clemente, John Cloyd Camara

Comaje, Mark Joseph Romero

De Honor, Denzel James Estrevillo

De Leon, Jhune Michael Antonio

Dulay, Jerome Lorenzo

Erivera, Jumel Barbarona

Galang,Arvin Villalon

Jamilla, Alvin Espiritu

Liwag, Michael Angelo Victorio

Lucilo, Jhon Joyce Pablo

Ramos, Rameer Pajarito

Ruta, Jerwen

Surio, Jerome Amador

Vereynato, Yuri Abrau

Villamor, Jayson Alzaga

Beles, Nikka Joy Maluson

Caasi, Elvira Gabino

Carinan, Janet Taracatac

De Vera, Rhealyn Llanda

Dizon, Claudine Miranda

Esogon, Varie Gracelyn Baybay

Escala, Cechell Mamasig

Haloc, Iris Claire Pascua

School Form 2 (SF2) Daily Attendance Report for learner

DATE (1st row for date, 2nd row for Day: M,T,W,TH,F)

(This cancel Form 1, Form 2 & STS Form 4 - Absenteeism and Dropout Profile)

*LEARNER'S NAME

(Last Name, First Name, Middle Name)

Aguilar, Denis Jimenez

MALE | TOTAL Per Day

Grade Level

Month Reporting


2/31

2 3 4 5 6 9 10 11 12 13 16 17 18 19 20 23 24 25 26 27 30



*LEARNER'S NAME


Herrera, Mara Dino

Jose, Jennielyn Dioquino

Oliveros, Edelyn Caraca

Soriano, Michaella Louise Grecia

Tadea, Gretchel Nozares

Santos, Mary Rose Anne Gadores

Tepase, Rose Ann Fernandez

Toralde, Bendan Perioles

Uy, Kristine De Gracia

Victoriano, Gabriel Ann

Villamor, Marvelle

GUIDELINES: 1. CODES FOR CHECKING ATTENDANCE

2. REASONS/CAUSES OF DROP-OUTS

a. Domestic-Related Factorsa.1. Had to take care of siblings

a.2. Early marriage/pregnancy

a.3. Parents' attitude toward schooling

a.4. Family problems

b. Individual-Related Factors

Enrolment as of JulyAverage Daily Attendance =

Percentage of Enrolment =

1. The attendance shall be accomplished daily. Refer to the codes for checking learners' attendance.

2. Dates shall be written in the preceding columns beside Learner's Name.

3. To compute the following:

Average daily attendance

* Automatic Generation thru LIS

centage of Attendance for the mont

blank- Present; (x)- Absent; Tardy (half sh

Upper for Late Commer, Lower for Cutting

Classes)

4. Every End of the month, the teacher/adviser submit this form to the office of the principal for recording of

summary table into the Form 3. Once signed by the principal, this form should be returned to the adviser.

Combined TOTAL PER DAY

FEMALE | DAILY TOTAL

a.

b.

c.

Total Daily Attendance

Number of School Days

Registered Learner as of End of the month

Registered Learner as of End of the Month

x 100

x 100

b.1. Illness4. Every End of the month, the teacher/adviser submit this form to the office of the principal for recording of

summary table into the Form 3. Once signed by the principal, this form should be returned to the adviser. b.2. Overage

5. Attendance performance of learner is expected to reflect in Form 137 and Form 138 every grading period b.3. Death

* b.4. Drug Abuse

b.5. Poor academic performance

b.6. Lack of interest/Distractions

b.7. Hunger/Malnutrition

c. School-Related Factors

c.1. Teacher Factor

c.2. Physical condition of classroomc.3. Peer influence

d. Geographic/Environmental

d.1. Distance between home and school

d.3. Calamities/Disasters

e. Financial-Related

4. Every End of the month, the teacher/adviser submit this form to the office of the principal for recording of

summary table into the Form 3. Once signed by the principal, this form should be returned to the adviser.

d.2. Armed conflict (incl. Tribal wars & clan

feuds)

Beginning of School Year cut-off report is every 1st Friday of School Calendar Days


3/31

2 3 4 5 6 9 10 11 12 13 16 17 18 19 20 23 24 25 26 27 30



*LEARNER'S NAME


e.1. Child labor, work

c oo orm : age o ________ f. Others


4/31


5/31


6/31


7/31

305452 NCR

AGE as of

(nos. of

years as per

last

birthday)

H

1

305452100024 M 8/4/1997 15 Nueva Ecija Tagalog Iglesia Ni

Cristo

785 Gula

2

305452100212 M 7/11/1998 14 Valenzuela Tagalog Catholic 101 Yan

3

305452100215 M 8/21/1997 15 Malabon Tagalog Catholic 15 Sitio

4

305452100249 M 9/20/1996 16 Malabon Tagalog Catholic 7 Arasit

5

305452100253 M 6/2/1997 16 Tagalog Catholic

6

305452100303 M 9/7/96 16 Malabon Tagalog Catholic 21-A Ati

7

305452100315 M 2/17/98 16 Manila Tagalog Catholic 98 Maco

8

305452100350 M 5/23/97 16 Caloocan Tagalog Catholic 149 Cris

9

305452100404 M 11/29/96 15 Manila Tagalog Catholic 3 Camac

10

305452100434 M 4/26/96 17 Malabon Tagalog Catholic 163 N2 M

11

305452100444 M 4/13/96 17 Malabon Tagalog Catholic

12

305388101757 M 9/3/98 14 Quezon City Tagalog Catholic 72 Mesi

13

305452100661 M 10/10/90 22 Quezon City Tagalog Catholic Area C, G

14

305452100714 M 12/31/97 15 Malabon Tagalog Catholic 146 Int,

15

305452100770 M 9/10/97 15 Malabon Tagalog Catholic 8 Socieg

16

305452100777 M 11/18/97 15 Manila Tagalog Catholic 41 E Dio

1

305452100110 F 1/9/97 16 Caloocan Tagalog Catholic 2 Vicent

2

305452100159 F 6/19/98 14 Manila Tagalog Catholic 131 Mac

3

305452100189 F 2/26/98 15 Malabon Tagalog Catholic B3L3 Pe

4

30452090269 F 12/31/96 16 Malabon Tagalog Catholic Sitio 6

5305452100291 F 6/26/97 15 Malabon Tagalog Catholic 161 M.H

6

305452100316 Escala, Cechell Mamasig F 9/20/97 16 Malabon Tagalog Catholic Blk 21 L

7

305452100320 F 11/15/96 15 Malabon Tagalog Catholic 50 Yang

8

305452100383 Haloc, Iris Claire Pascua F 1/10/98 15 Malabon Tagalog Catholic 8 Indust

9

305452100386 Herrera, Mara Dino F 8/28/94 18 Malabon Tagalog Catholic 69-A Re

Carinan, Janet Taracatac

De Vera, Rhealyn Llanda

Dizon, Claudine Miranda

Esogon, Varie Gracelyn Baybay

Vereynato, Yuri Abrau

Villamor, Jayson Alzaga

Beles, Nikka Joy Maluson

Caasi, Elvira Gabino

Lucilo, Jhon Joyce Pablo

Ramos, Rameer Pajarito

Ruta, Jerwen

Surio, Jerome Amador

Erivera, Jumel Barbarona

Galang,Arvin Villalon

Jamilla, Alvin Espiritu

Liwag, Michael Angelo Victorio

De Honor, Denzel James Estrevillo

De Leon, Jhune Michael Antonio

Dulay, Jerome Lorenzo

School Form 1 (SF (This replace Form 1, Master List & STS F

LRNSex

(M/F)

BIRTH DATE

(mm/ dd/yy)

BIRTH PLACE

(Province)

MOTHER

TONGUE

IP

(Specify

Ethnic Group)

NAME


School Name

School ID

TINAJEROS NATIONAL HIGH SCHOOL

Region Division

RELIGION

Aguilar, Denis Jimenez

Clemente, John Cloyd Camara

Comaje, Mark Joseph Romero


8/31

AGE as of

(nos. of

years as per

last

birthday)

LRNSex

(M/F)

BIRTH DATE

(mm/ dd/yy)

BIRTH PLACE

(Province)

MOTHER

TONGUE

IP

(Specify

Ethnic Group)

NAME

(Last Name, First Name, Middle Name)RELIGION

10

305452100408 Jose, Jennielyn Dioquino F 7/10/98 14 Malabon Tagalog Catholic 288 M

11305452100544 Oliveros, Edelyn Caraca F 10/28/97 15 Manila Tagalog Catholic 12B S

12

305452100678 Santos, Mary Rose Anne Gadores F 10/1/97 16 Malabon Tagalog Catholic 156 S

13

30452100710 F 4/25/97 15 Malabon Tagalog Catholic Sanch

14

305452100718 Tadea, Gretchel Nozares F 5/28/97 16 Malabon Tagalog Catholic 101 R

15

305452100730 Tepase, Rose Ann Fernandez F 11/3/95 17 Cavite Tagalog Catholic Sitio 6

16

305452100737 F 9/6/97 15 Malabon Tagalog Catholic Sitio 6

17

305452100760 F 12/13/97 15 Malabon Tagalog Catholic 101 A

18305452100773 F 11/3/97 15 Malabon Tagalog Iglesia Ni

Cristo

20 Ca

19305452100778 F 5/18/97 16 Valenzuela Tagalog Catholic 5 A Re

Indicator Code Required Information Indicator Code Required Informatio

Transferred Out T/O Name of Public (P) Private (PR) School & Effectivity Date CCT Recipient CCT

Transferred IN T/I Name of Public (P) Private (PR) School & Effectivity Date Balik-Aral B/A Name of school last a

Dropped DRP Reason and Effectivity Date Learner With Dissability LWD

Accelarated ACL

List and code of Indicators under REMARK column

CCT Control/reference

Soriano, Michaella Louise Grecia

Toralde, Bendan Perioles

Uy, Kristine De Gracia

Victoriano, Gabriel Ann

Villamor, Marvelle


9/31

REMARK/S

Contact

Number

(Please refer to

the legend on

last page)

nt)


10/31

REMARK/S

Contact

Number

(Please refer to

the legend on

last page)

nt)

Date:

Certified Correct:

ignature of School Head over Printed Nam

Ma. Victoria R. De Gulan


11/31

School ID305452

School Year

School Name IV

Issued Returned Issued Returned Issued Returned Issued Returne

1Aguilar, Denis Jimenez

6/4/2013 2/24/2014 6/4/2013 2/24/201

2Clemente, John Cloyd Camara

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

3Comaje, Mark Joseph Romero

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

4De Honor, Denzel James Estrevillo

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

5De Leon, Jhune Michael Antonio

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

6Dulay, Jerome Lorenzo

6/4/20 13 2/24/20 14

7Erivera, Jumel Barbarona

6/4/20 13 2/24/20 14

8Galang, Arvin Villalon

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

9Jamilla, Alvin Espiritu

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

10Liwag, Michael Angelo Victorio

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

11Lucilo, Jhon Joyce Pablo

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

12Ramos, Rameer Pajarito

6/4/2013 2/24/2014 6/4/2013 2/24/201

13Ruta, Jerwen

6/4/20 13 2/24/20 14

14Surio, Jerome Amador

15Vereynato, Yuri Abrau

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

16Villamor, Jayson Alzaga

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013 2/24/201

TOTAL FOR MALE | TOTAL COPIES

Grade Level

FILIPINO ENGLISH

ENGLISH

EXPRESSWAYS IV

MATH

Date Date Date Date

2

(This replace Form 1 & Inventory of Text Book)

School Form 3 (SF3) Books Issued and

TINAJEROS NATIONAL HIGH SCHOOL

NO.

SCIENCE

*LEARNER'S NAME


Advanced

Algebra

Trigonometry

and Statistics

Physics

Textbook


12/31

Issued Returned Issued Returned Issued Returned Issued

FILIPINO ENGLISH

ENGLISH

EXPRESSWAYS IV

MATH

Date Date Date

NO.

S

*LEARNER'S NAME


Advanced

Algebra

Trigonometry

and Statistics

Physic

Textb

1Beles, Nikka Joy Maluson

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

2Caasi, Elvira Gabino

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

3Carinan, Janet Taracatac

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

4De Vera, Rhealyn Llanda

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

5Dizon, Claudine Miranda

6/4/2013 2/24/2014 6/4/2013

6Escala, Cechell Mamasig

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

7Esogon, Varie Gracelyn Baybay

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

8Haloc, Iris Claire Pascua

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

9Herrera, Mara Dino

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

10Jose, Jennielyn Dioquino

6/ 4/2013 2/ 24/ 2014 6/4/2013 2/24/2014 6/4/2013

11Oliveros, Edelyn Caraca

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

14 6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

12Soriano, Michaella Louise Grecia

6/ 4/2013 2/ 24/ 2014 6/4/ 2013 2/24 /2014 6/4/2013

13

Tadea, Gretchel Nozares6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

15Tepase, Rose Ann Fernandez

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

16Toralde, Bendan Perioles

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

17Uy, Kristine De Gracia

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

18Victoriano, Gabriel Ann

6/ 4/2013 2/ 24/ 2014

19Villamor, Marvelle

6/4/2013 2/24/2014 6/4/2013 2/24/2014 6/4/2013

TOTAL FOR FEMALE | TOTAL COPIES

TOTAL LEARNERS | TOTAL COPIES

* Automatic Generation thru LIS

GUIDELINES: Prepar

2. The Date of Issuance and the Date of Return shall be reflected in the form.

Santos, Mary Rose Anne Cadores

4. The Total Number of Copies of Books Returned at the EoSY shall be reflected in the form.

3. The Total Number of Copies issued at BoSY shall be reflected in the form.

1. Title of Books Issued to each learner must be recorded by the class adviser.


13/31

Region Division Distric

School ID

School Name School Year

M F T M F T M F T M F T M F T M F T M

ELEMENTARY/SECONDARY:

# Need home visitation as per DECS Service Manual (page, section)

GUIDELINES:

2. Furnish copy to Division Office: a week after July 31, October 30 & March 31

3. Teachers who are handling advisory class shall be reported.

TOTAL

1. This forms shall be accomplished every end of the month using the summary box of Form 1 submitted by the teachers/advisers to update figures for the month.

Columns for "Cumulative as of Previous Month" require the figures in "cumulative total reported from previous month".

GRADE 2/GRADE 8

GRADE 3/GRADE 9

GRADE 4/GRADE 10

GRADE 5/GRADE 11

GRADE 6/GRADE 12

TOTAL FOR NON-GRADED

GRADE 1/GRADE 7

KINDER

NAME OF ADVISER

GRADE/

YEAR

LEVEL

SECTION

REGISTERED

LEARNER

(As of End of the

Month)

ATTENDANCE

4. Small school that has one section per grade/year level are not required to fill the columns "Name of Adviser, Grade/Year Level & Section". Instead, they will only

School Form 4 (SF4) Monthly Learner's Movement and At

DROPPED OUT

Average Percentage(A) Cumulative as

of Previous Month(B) For the Month

(A+B) Cumulative

as of End of the

Month

(A) Cum

of Previo

Region: Division: District

(This replace Form 3 & STS Form 4-Absenteeism and Dropout Profile)


14/31

accomplish the summary column per grade/year level.


15/31

T

1

)

as of

he


16/31

Region Division District

Curriculum

Grade Level Sectio

INCOMPLETE SUBJECT/S

(This column is for K to 12 Curriculum and remaining RBEC i

High School. Elementary grades level that still implementing

RBEC need not to fill up this column)

Completed as of end of current

SYas of End of the current SY

School Form 5 (SF 5) Report on Promotion & Level of Proficiency(This replace Forms 18-E1, 18-E2, 18A)

LRN

GENERAL

AVERAGE

(Numerical Value

in 3 decimal

places)

ACTION TAKEN:

PROMOTED or

RETAINED

(RBEC only)

School Name

School ID

LEARNER'S NAME (Last

Name, First Name, Middle Name)

School Year


17/31


(This column is for K to 12 Curriculum and rema

High School. Elementary grades level that still

RBEC need not to fill up this colum


SYas of End of

LRN

GENERAL

AVERAGE

(Numerical Value

in 3 decimal

places)

ACTION TAKEN:

PROMOTED or

RETAINED

(RBEC only)



TOTAL FEMALE

COMBINED

TOTAL MALE


18/31


(This column is for K to 12 Curriculum and remaining RBEC in

High School. Elementary grades level that still implementing

RBEC need not to fill up this column)


SYas of End of the current SY

LRN

GENERAL

AVERAGE

(Numerical Value

in 3 decimal

places)

ACTION TAKEN:

PROMOTED or

RETAINED

(RBEC only)



* May generate thru Learner's Information System or may lift from Master List of Learners.


19/31

TOTAL

TOTAL


20/31

:

al rating

the

dviser

eral

total

ed and

he

ent

/GSSP


21/31

f ________


22/31

MALE FEMALE TOTAL MALE FEMALE TOTAL MALE FEMALE TOTAL MALE FEMALE TOTAL MALE FEMALE TOTAL MALE FE

PROMOTED

LEVEL OF PROFICIENCY MALE FEMALE TOTAL MALE FEMALE TOTAL MALE FEMALE TOTAL MALE FEMALE TOTAL MALE FEMALE TOTAL MALE FE

Prepared and Submitted by: Reviewed & Validated by: Noted by:

SCHOOL HEAD DPO/EPS SCHOOLS DIVISION

GUIDELINES:

2. This report together with the copy of Report for Promotion submitted by the class adviser shall be forwarded to the Division Office by the end of the school year.

3. The Report on Promotion per Grade Level is reflected in the End of School Year Report of GESP/GSSP

SUMMARY TABLE

1. After receiving and validating the Report for Promotion submitted by the class adviser, the School Head shall compute the Total for Grade Level in order to reflect the result in ea

Nos. of ADVANCED (A:

90% and above)

Nos. of PROFICIENT (P:

85% -89%)

Nos. of APPROACHINGPROFICIENCY

(AP: 80%-84%)

Nos. of DEVELOPING (D:

75%-79%)

GRADE 2 / GRADE 8 GRADE 3 / GRADE 9 GRADE 4 / GRADE 10 GRADE 5 / GRADE 11 GRADE

School Form 6 (SF6) Summarized Report on Promotion

(This cancel Form 20)

RETAINED (RBEC)

TOTAL

Nos. of BEGINNNING

(B: 74% and below)

and Level of Proficiency

GRADE 1 /GRADE 7

School Name

School ID Region Division

District


23/31

TOTAL

TOTAL


24/31


25/31

Region

Degree / Post

GraduateDAY From To

Ave. Minutes per Day

(A) Nationally-Funded Teaching Related Items

Number ofIncumbent

Title of Plantilla Position

(as appeared in the appointmentdocument)

(C ) Other Appointments

Nature of Appointment and Designation(Contractual, Substitute, Volunteer & others)

KINDER

Number ofIncumbentTitle of Plantilla Position(as appeared in the appointment document)

(B) Nationally-Funded Non Teaching Items

Nature of

Appointment

Position/

Designation

Subject Taught(include

Grade & Section) &

Other Ancillary

Assignment(Please

Specify)



* Daily Program (time dEDUCATIONAL QUALIFICATION

Major/

SpecializationMinor

No.Name of School Personnel

(Arrange by Position, Descending)Sex

Fund

Source

School Form 7 (SF7) School Personnel Assignment L ist and Basic Profi le(This replace Form 12-Monthly Status Report for Teachers, Form 19-Assignment List,

Form 29-Teacher Program and Form 31-Summary Information of Teachers)

Scho

School ID

School Name

Division

District


26/31

Degree / Post

GraduateDAY From

Nature of

Appointment

Position/

Designation


Grade & Section) &

Other Ancillary

Assignment(Please

Specify)

* Daily ProgEDUCATIONAL QUALIFICATION

Major/

SpecializationMinor



Fund

Source

GUIDELINES: Submit

(Sig

Ave. Minutes

Ave. Minutes

Ave. Minutes

Ave. Minutes

2. All school personnel, regardless of position/nature of appointment should be included in this form and should be listed from the highest rank down to

1. This form shall be accomplished at the beginning of the school year by the school head. In case of movement of teachers and other personnel during

SY, updated Form 19 must submit to the Division Office .

Ave. Minutes

Ave. Minutes


27/31

Degree / Post

GraduateDAY From

Nature of

Appointment

Position/

Designation


Grade & Section) &

Other Ancillary

Assignment(Please

Specify)

* Daily ProgEDUCATIONAL QUALIFICATION

Major/

SpecializationMinor



Fund

Source

the lowest. This form shall also serve as inventory list of school personnel.

3. * Daily Program Column is for teaching personnel only


28/31

Pls. Check:

( ) Transferee ( ) Balik-Aral

( ) Private ( ) Public

Name of Previous School: _________________________________________________________

Division: ______________________________ Province/Region : ______________________________

A. PERSONAL DATA (to be accomplished by the parent/pupil during enrolment)

Name of Learner: ______________________________________ LRN: __________________

Date of Birth : _________________________________ Place of Birth : ____________________

Sex:___________ Current Address/Residence:

SY House #/Street

SYSY

SY

SY

SY

Nationality: __________________________ Religion: ______________

Name of Father: _______________________________ Occupation : ___________________

Highest Educational Attainment of Father: ______________________________

Name of Mother: _______________________________ Occupation : ______________________

Highest Educational Attainment of Mother: ______________________________

Name of Guardian (if Guardian is not the parent): ______________________________________

Relationship to Guardian: ________________________________

Contact Number of Parents/Guardian: _________________________________

Currently living with at least one of the parents : ( ) yes ( ) no

Dialect use to communicate within the family: ______________________

Recipient of 4P's* : Yes/ No SY SY

SY SY

SY SY

B. MEDICAL / HEALTH RECORD (annual updating by the health officer/teacher)

b.1 Nutritional Status

SY_____ SY_____ SY_____ SY_____ SY_____Weight (kg)

Height(m)

Body Mass Index (BMI)

Nutritional Status

(e.g.Normal,Below Normal,Above Normal,Severely Wasted)

b.2 Learner's record of ailments: (pls. check) (to be examined by the nurse)

SY_____ SY_____ SY_____ SY_____ SY_____

( ) Pediculosis

( ) Tinea Flava

( ) Scabies

( ) Eye infection

( ) Squinting eyes

( ) Otitis Media

( ) Impacted Cerumen

( ) Colds/Cough

( ) Sinusitis

( ) Ringworm

( ) Nosebleed

( ) Decayed Tooth

( ) defective speech

( ) Sore Throat( ) Tonsilitis

( ) Asthma

*Programang Pantawid ng

Pamilyang Pilipino

Barangay

LEARNER DATA SHEET

Republic of the Philippines

Department of Education

Region: _____________________________

Division : ____________________________

School: _______________________________


29/31

( ) Allergy

( ) Bronchitis

( ) Primary Complex

( ) Convulsions

( ) Frequent headache

( ) Heart problem

( ) Frequent Stomach Ache

b.3 Immunization

Learner's immunization shots are complete and current: yes /no

SY SY

Sports Talent Test (PFSTT) SY_____ SY_____ SY_____ SY_____ SY_____

b.4.1. Muscular Fitness

Partial: Curl Ups

Trunk: Lift (cm)

90-Degrees push- ups

b.4.2. Flexibility Fitness Sit and Reach

Left leg bent (cm)

Right leg bent (cm)

Shoulder Flexibility

Right arm up (cm)

Left arm up (cm)

b.4.3. Physiological Fitness

1km run - Time: (min/sec)

b.5. Sports Talents

b.5.1 Anthropometrics

Sitting Height (cm)

Arm Span (cm)

b.5.2. Muscular Power

Standing Long Jump (m)

Basketball Pass (m)

b.5.3 Speed

40-meter sprint (sec.)

C. FAMILY& COMMUNITY PROFILE

Type of community ( ) Residential ( ) Commercial ( )Agricultural ( ) IndustrialDisaster Prone/ Armmed Conflict ( ) Yes ( ) No

Identified as IP Community? If yes, specify: _____________________________________________

With electrical services (Home) ( ) Yes ( ) No

With water services (Home) ( ) Yes ( ) No

Distance of Home from/to school: ___________ (km) Estimated time in going to school : ______ (h

Meansof going to school: ( ) walking ( ) by boat ( ) vehicles

D. EDUCATIONAL PROFILE (see attached Form 137)

GUIDELINE:

Other illness(specify):

The Learner Data Sheet shall be accomplish by the parent/pupil during enrolment. While, the m


30/31

SY_____ SY_____

SY_____ SY_____

*Orderof ailments (eyes, ears, etc.)

Municipality/Province


31/31

SY_____ SY_____

*to be commented by PE Teachers

( ) Fishing ( ) Mining

our)

edical/health record shall be accomplish by

Books Issued and Returned

Documents

Transcript of Books Issued and Returned