REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION III
DIVISION OF NUEVA ECIJA
DISTRICT OF TALAVERA NORTH
LOMBOY ELEMENTARY SCHOOL
S.Y. 2017-2018

CHECKLIST FOR HOME VISITATION

Name of Pupil: ________________________________________________________________________

Parent/Guardian: ______________________________________________________________________
Date: ________________________________________________________________________________

Check the _____ which corresponds to the parent’s/ guardian’s answer.

1. What is the first thing that your child does after class?
_____Assignment _____Play/watch TV ____Home chores
Other, please specify _____________________________________

2. What time does he/she sleep?

_____ 9 and beyond _____ not later than 11

3. Do you ask him/her about school or check his/her assignment?

_____Yes _____No _____Sometimes

4. Who helps him/her on his /her assignment?

_____Father _____Mother _____Siblings
Other, please specify _____________________________________

5. On weekends, do you check his/her notes?

_____Yes _____No _____Sometimes

6. How is he/she as a son/daughter?

______Fair _____Good _____Very Good

7. How is his/her relationship with his /her siblings?

______Fair _____Good _____Very Good

8. Does he/she have a regular playtime?

_____Yes _____No

9. How do you see him / her as a pupil?

______Fair _____Good _____Very Good

10. Do you have a regular job?

_____Yes _____No
If Yes, please specify ___________________________________________

Remarks: ______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

________________________________
Parent’s / Guardian’s Signature
KARL EDRIAN ABENDÑO
Teacher