Republic of the Philippines

Department of Education
Region IV-A CALABARZON

DIVISION OF BATANGAS
Provincial Sports Complex, Bolbok, Batangas City

PAROLA ELEMENTARY SCHOOL

Anecdotal record

Pupil: _______________________________ Teacher: ______________________

Date:_______________________________
Place: ______________________________
Incident:____________________________
Comment:___________________________
Recommendation:________________________________________________________
___________________________________________________________________________
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Republic of the Philippines

Department of Education
Region IV-A CALABARZON

DIVISION OF BATANGAS

Provincial Sports Complex, Bolbok, Batangas City

PAROLA ELEMENTARY SCHOOL

INTERVIEW record
Name:___________________________
Section:______________

Grade and

Interview Requested by:

Pupil: __________________
______________________

Teacher:

Parents: ________________
__________________

Other Person:

Chief Reason / Reasons of Interview:

___________________________________
____________________________________
____________________________________
Summary of the Interview:
___________________________________________
___________________________________________
___________________________________________

Result of the Interview:

___________________________________________
___________________________________________
___________________________________________

Date of the next schedule of interview:

_________________________________

Guidance Counselor
_____________________
Republic of the Philippines

Department of Education
Region IV-A CALABARZON

DIVISION OF BATANGAS

Provincial Sports Complex, Bolbok, Batangas City

PAROLA ELEMENTARY SCHOOL

Referral form for teachers use

Case No: ________________
_____________________
Name of Pupil: _______________________________________
Address : ____________________________________________
Age: ________________________________________________
Sex: ________________________________________________
_____________________

Grade and Section

Rank in the Family:

Name of Guardian

Father:_______________________________
Occupation:
__________________________
Mother: _____________________________
Occupation:
__________________________

Statement of The Problem:

_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
___________________________________________________________________________________________
Pls. check which of the following identify symptoms stand out prominently as observed in the
referred pupil.
____________________ 1. Truency
____________________ 2. By Bullying
____________________ 3. Cheating
____________________ 4. Stealing
____________________ 5. Gambling
____________________ 6. Drinking
____________________ 7.Dis-Obedience
____________________ 8. Habitual tardiness
____________________ 9. Irregular attendance
____________________ 10. Others ______________________________
Referred by:
____________________
Teacher
Date of Referral
_____________________
Republic of the Philippines

Department of Education
Region IV-A CALABARZON

DIVISION OF BATANGAS

Provincial Sports Complex, Bolbok, Batangas City

PAROLA ELEMENTARY SCHOOL

Liham para sa magulang

Petsa:_______________

Minamahal naming magulang:

Mapitagan po naming pinababatid sa inyo na ang inyong anak na si
_________________________

na nasa ___________________ Baitang ng ating Mababang Paaralan ng pacita Madrigal

Warns ay
_________________________1. Kailangan po ang higit na tulong at parangal ninyo bukod sa
pagsisikap ng
mga guro
_________________________
2.
May
nagawang
hindi
mabuti
:
____________________________________
_______________________ _3. Palaging tumatakas sa klase
_________________________4. May _______________ na araw na hindi pumapasoksa klase
_________________________5. Madalas mahuli sa klase
_________________________6. Hindi gumagawa ng Takdang Aralin
_________________________7. Hindi nagdadala ng kagamitan sa pag-aaral.
Ang inyong tulong ay mahigit naming kinakailangan kaya ipinapakiusap naming sa
inyo na alang-alang sa ikabubuti ng inyong anak ay magsadya kayo ditto.
Ang
hanapin
po
ninyo
ay
si
Gng.
/
Bb.
/
G.
____________________________________________
Kanyang guro.
Pinagtibay
_______________________
Punong Guro
Gumagalang,
________________________