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REPUBLIC OFTHEPHILIPPINES

REGION IV-A CALABARZON


DIVISION OF BATANGAS
DISTRICT OF AGONCILLO
AGONCILLO NATIONAL HIGH SCHOOL

Barangay:____________________________________ Division:____________________________
Municipality:_________________________________ Region:_____________________________

NAME DEMOGRAPHIC INFORMATION RESIDENCE DISABILITY

Date of Present Number of Is residence Has disability?


Last First Middle Gender Age Years in Present Permanent?
Birth Address Address? (YES/NO) (YES/NO)
With Birth
Certificate?
(YES/NO)

ASK:"Is the child a permanent resident? (YES/NO), If yes, follow up, do the residents plan on moving moving out"

Types of Disabilities: EDUCATIONAL ATTAINMENT


1. Visula Impairment 6. Serious Emotional Disturbances C7- Completed Grade 7
2. Hearing Impairment 7. Autism C8- Completed Grade 8
3. Intellectual Disability 8. Orthopedic Imapairment C9- Completed Grade 9
4. Learning Disability 9. Special Health Problem C10- Completed Grade 10
5. Speech/Language Impairment 10. Multiple Disabilities
PHILIPPINES
ALABARZON
ATANGAS
GONCILLO
L HIGH SCHOOL

DISABILITY EDUCATIONAL STATUS FUTURE ENROLLMENT


If no, state
If studying Planning to If yes, Specify
If yes, Specify Currently If yes, Specify If no, State reason for not
Educational through ADM, study next the name of
type of Studying? the Name of reason for not Specify planning to
Attainment (YES/NO) type of School year? Prospective
Disability the School studying study next
ADM (YES/NO) School school year

INTERVIEWER NAME AND SIGNATURE

DATE OF INTERVIEWS