PUPIL FAMILY BACKGROUND QUESTIONAIRE

1. Pupil’s Name _______________________________________________________ Age ____________ Sex ________

Address _______________________________________________________________________________________
Number Street Municipality/City/Province
Nationality _____________________________________________ Religion ________________________________
Ethnic Affiliation _________________________________________________________________________________
Date of Birth _______________________________ Place of Birth ________________________________________
Birth Registered? Yes ____________________ No _____________________

2. Has pupil ever dropped out of school?

Yes No
If yes, for how long : _________________________
What reason(s) : ______________________________________________________________________

3. Distance from home to school: _________________ km

Means of transportation to school:
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 (specify) ____________

7. Who helps the pupil in doing homework?

None Both Parents Mother Father Others )specify) ______________

8. Parental Religious Affiliation

Information Father Mother
Living Deceased Living Deceased
Name
Age
Address
Nationality
Ethnic Affiliation
Religion
Language(s) dialect (s) spoken

9. Parental Marital Status

Married Live-in Widow(er) Annulled Separated
Others (specify) _______________________________________________________________________

10. List all members of the household including those who migrated. Specify/check the information needed.
Sex Age Relation Migrate Education Occupation
M F ship to d (How Enrolled/C Highest NFE Full Part
Name of Household Member Pupil long?) ompleted Grade/ Course Time Time
ECE* Year/Degree completed
Completed

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

11. Is the family a member of any community development organization? Yes No
If yes, please specify _____________________________________

12. Monthly Household Income

Below P1,000 P1,000-P2,500 P2,501-P5000
P5,001-P8,000 P8,001-P15,000 Over P15,000

13. Information about family dwelling

a. The family:
owns house and lot rents house others, please specify ____________________
b. Type of house:
concrete Semi-concrete others, please specify ____________________
c. Type of toilet:
flush pit water sealed no toilet others, please specify ______________
d. Source of water supply:
faucet/tap water deep well others, please specify ______________
e. Power Source:
electricity kerosene lamp(gaas) others, please specify ______________

14. Which of the following are available at home?

TV newspaper magazine
Radio books others, please specify _____________________

Accomplished by: _________________________________

Date: _________________________________