Republic of the Philippines

Department of Education
Region XI
Schools Division of Davao del Norte
KAPALONG NATIONAL HIGH SCHOOL

HOME VISIT RECORD

Date
Time
I. Student’s Personal Information:
Name Nick Name Grade
Last Name, First Name, Middle Name
Place of Birth Date of Birth Gender
II. Family Information:
Father
Name Age Occupation
Last Name, First Name, Middle Name
Salary Educational Attainment Religion
Mother
Maiden Name Age Occupation
Last Name, First Name, Middle Name
Salary Educational Attainment Religion
Guardian
Name Relationship Age
Last Name, First Name, Middle Name
Occupation Salary Educational Attainment
Business Address of Parent/Guardian
Position of the Pupil in the Family (Eldest to Youngest)
Number of Siblings

III. Economic Information

1. Financial Status
Excellent (above 78K php) Good (31K=<78K php) Moderate (7K=<31K php)  Poor (below 7K)
2. Type of Dwelling
Single Attached Row Duplex Mansion Others
3. Materials of the House
A. Concrete B. Wood A & B Make Shift Others
4. Type of House Possession
Owned Rented  Living with other family

IV. Demographic Profile

1. Language Spoken
A. Mother Tongue  B. Filipino C. English Only A & B A, B, & C
2. Religious Affiliation

3. Ethnicity

4. Distance Away from School

Near (below 5km)  Far (5km-10km)  Very Far (beyond 10km)

IV. Scholastic Standing:

1. General Average from Previous Level
Outstanding (90 above)  Very Satisfactory (85-89) Satisfactory (80-84)
Fairly Satisfactory 75-79 Did Note Meet Expectation (below 75)
2. Have you been retained?
YES  NO If YES, how many times?

http://depedtambayanph.blogspot.com/