Division of Laoag City

District I
GABU ELEMENTARY SCHOOL
Laoag City

PUPIL FAMILY BACKGROUND QUESTIONNAIRE

1. Pupils Name
___________________________________________
Age: _______ Sex: _________
Address __________________________________________________________________________
House No. Street
Barangay
Municipality/City/Province
Nationality ___________________________
Religion ___________________________________
Ethnic Affiliation _______________________ Place of Birth ______________________________
Birth Registered? Yes _______ No _______
2. Has the pupil ever dropped out from school?
Yes
No
If yes, how long? _________________________________
What reason(s) ______________________________________________________________
3. Distance from home to school _____ km
Means of transportation (please check)
Car
Jeepney

Pedicab

Motorized side car

others _______________
4. Has any member of the family ever dropped out of school?

Yes

No

5. Is the pupil receiving any type of financial assistance to attend school?

Yes

No
If yes, from what source(s) (specify) ___________________________________________________
6. With whom does the pupil live?
Both Parents

Mother

Father

Others

Mother

Father

(specify) __________________
7. Who helps the pupil in doing homework?
None
Both Parents
Others (specify) __________________
8. Information on Parents
Information
Name
Age
Address
Nationality
Ethnic Affiliation
Religion
Language(s)/Dialec
t(s)

Father
Living

Mother
Living

Deceased

Deceased

spoken
9. Parental Marital Status (Please check)
Married
Live-in

Widow(er)

Annulled

Separated

Others (specify) __________________

10.List all the members of the household including those who have migrated.
Specify/check the information needed.
Name of
Migrated
Relationshi
(how
Household Sex Age
Education
p to Pupil
long)
Member
Highest
ALS
Grade/Yea
Enrolled/
Course
r/
Complet
M F
Degree Complet
ed ECE*
Complete
ed
d

*Early Childhood Education (services such as day care and pre-school)

11.Is the family a member of any community development organization?
Yes
No
12.Monthly Household Income (Please check)
Below Php 1,000
Php 5,001 Php 8,000
Php 1,000 Php 2,500

Php 8,001 Php 15,000

Php 2,501 Php 5,000

Php 8,001 Php 15,000

13.Information about family dwelling

a. The family (Please check)
owns a house and lot

rents house

Others (specify) _______________________________________

b. Type of house (Please check)
concrete

semi-concrete

Others (specify) __________________

c. Type of toilet (Please check)

Occupation

flush

no toilet

pit

water sealed

Others (specify) __________________

d. Source of water supply (Please check)

faucet/tap water
deep well
Others (specify) __________________
e. Power source (Please check)
electricity

kerosene lamp (gas)

Others (specify) __________________

14.Which of the following are available at home? (Please check)
television
radio
magazine

books

Others (specify) __________________