Republic of the Philippines

Department of Education
Cordillera Administrative Region
Schools Division of Kalinga
Southern Pinukpuk District
Allaguia Elementary School

LEARNING ASSESSMENT NEEDS

ANECDOTAL RECORD
A. PERSONAL PROFILE:

Name: ________________________________________ Age: _____ Sex: _____ Grade: _____ Address:

_________________________________ Date of Birth: ______________ Place of Birth: ________________
______________ __________________ Birth registered? Yes ( ) No ( ) Religion: ___________________
Nationality: ________Talent/Skills: _______________________________________Recipient of financial
assistance? Yes ( ) No ( ) Source: _______________ Pupil is living with parents ( ) mother ( ) father ( )
uncle/auntie ( ) Grandparents ( ) others: ____________ Language spoken: __________________ Name of
father: _____________________________________ Age: __________ Living: ( ) Deceased: ( ) Occupation:
___________________ Monthly Income: _____________ Other source of income: _______________
Educational attainment: ___________________________ Ethnic affiliation: ____________________________
Name of mother: ____________________________________ Age: ____________ Living: ( ) Deceased: ( )
Occupation: ___________________ Monthly Income: _____________ Other source of income: ____________
Educational attainment: ___________________________ Ethnic affiliation: ____________________________
Parents status: Married ( ) Single parent ( ) Separated ( ) Widow ( ) Others: ___________ Number of
Brothers: _______ Number of sisters: _________ others living with the family: ____________
Brother in College: (year & course) _____________________________________________________________
Senior HS ( ) Junior HS ( ) Elementary ( )
Sister in College: (year & course) ______________________________________________________________
Senior HS ( ) Junior HS ( ) Elementary ( )
Distance of school from home: _______________________ Means of Transportation: ____________________
House/lot ownership: _________________________ Type of house: __________________________________
Source of water supply: ______________________________ Source of power supply: ____________________
Materials/Appliances available at home? ________________________________________________________

B.ACADEMIC PROFILE AND OTHER RELATED INFORMATION:

SUBJECTS First Grading Second Third Grading Fourth Final Grade

Grading Grading
Edukasyon sa
Pagpapakatao
Mother Tongue Based
Mathematics
Filipino
English
Araling Panlipunan
MAPEH
Has failing grades in: ______________________________ Reason: ___________________________________
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Has back subject in: ______________________________ Reason: ____________________________________
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Repeated a grade level? Yes ( ) No ( ) Reason: ____________________________________________________
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NAT RESULT: GRADE III: ______ GRADE IV: ______ Study hours per day: _______________________________
Pupil drop out history: Yes ( ) No ( ) How long?: ________________ Reason: __________________________
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Family member drop out? Yes ( ) No ( ) How long?: _______________ Reason: _______________________
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Person who helps child in homework? _____________________ Reading level: (F) ______________________
No. of days absent: _______________ Reason: __________________________________________________
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No. of days late: ________________ Reason: ____________________________________________________
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Member/ Officer in what organization/s: ________________________________________________________
Learning difficulties: _________________________________________________________________________
Home visitation findings: _____________________________________________________________________
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A. CONDUCT/ BEHAVIOR INFORMATION:

Reported conduct or misbehavior: ______________________________________________________________

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Suspensions or other disciplinary actions: ________________________________________________________
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Abused? Yes ( ) No ( ) Reason: ________________________________________________________________
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Others: ____________________________________________________________________________________
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D.MEDICAL HEALTH PROFILE:

Dates reported absent due to sickness: __________________________________________________________

Reported sickness/illness:
Severe malnutrition: ( ) Moderate malnutrition ( ) Mild malnutrition ( )
Other health problem? _______________________________________________________________________

E. ANALYSIS: _____________________________________________________________________________
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F. FINDINGS:
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G. RECOMMENDATIONS:
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