(COPY, PASTE, ANSWER THEN SEND TO YOUR TEACHER)

Grade Level (for SY 2020-2021):

FOR INCOMING SHS STUDENTS ONLY: State your SHS Track:
Last Name:
First Name
Middle Name
Father's Full Name:
Highest Educational Attainment:
1.Elem Grad
2.HS Grad
3.Coll Grad
4.Vocational
5.Master’sDoctorate Degree
6.Did not attend school
Employment Status:
1.Full time
2.Part time
3.Self Employed
4.Not Working
Working from home due to ECQ?
1.Yes
2.No
Active Contact Number
Mother’s Full MAIDEN NAME:
Highest Educational Attainment:
1.Elem Grad
2.HS Grad
3.Coll Grad
4.Vocational
5.Master’sDoctorate Degree
6.Did not attend school
Employment Status:
1.Full time
2.Part time
3.Self Employed
4.Not Working
Working from home due to ECQ?
1.Yes
2.No
Active Contact Number
Guardian's Full Name:
Highest Educational Attainment:
1.Elem Grad
2.HS Grad
3.Coll Grad
4.Vocational
5.Master’sDoctorate Degree
6.Did not attend school
Employment StatusWorking from home due to ECQ?
1.Yes
2.No
Active Contact Number:
D1. How does your child go to school? Choose all that applies.
1.Walking
2.Public commute
3.Family-owned vehicle
4.School service
D2. How many of your household members )including the enrollee) are studying in School Year 2020-
2021 from Kinder to College? Please specify each.
1.Kinder-1
 2.G1-,
3.G2-
4.G3-
5.G4-
6.G5-
6.G6-
8.G7-
9.G8-
10.G9-
11.G10-
12.G11-
13.G12-
14.College-
D3. Who among the household members can provide instructional support to the child's distance
learning? Choose all that applies. (You can choose as many as possible)
1.Parents/guardian
2.Elder siblings
3.Grand parents
4.Extended members of the family
5.Others (tutor,house helper)
6.None
7.Able to do independent learning
D4. What devices are available at home that the learner can use for learning? You can choose as many
as possible.
1.Cable TV
2.Non-cable TV
3.Basic cellphone
4.Smartphone
5.Tablet
6.Radio
7.Desktop computer
8.Laptop
9.None
10.others
D5. Do you have a way to connect to the internet?
1.Yes
2.no
D6. How do you connect to the internet? Choose all that applies.
1.Own mobile data
2.Own broadband internet
3.Computer shop
4.Other places outside the home with internet connection
5.one
D7. What distance learning modality/ies do you prefer for your child?Choose as many as possible.
1.Online learning
2.Television
3.Radio
4.Modular learning
5.Combination of face to face with other modalities
6.others
D8. What are the other challenges that may affect your child's learning process through distance
education? Choose all that applies.
1.Lack of available gadgets/equipment
2.Insufficient load/data allowance
3.Unstable mobile internet connection
4.Existing health conditions
5.Difficulty in independent learning
6.Conflict with other activities
7.High electrical consumption
8.Distractions
9.others