LEANERS INFORMATION

LAST NAME: ________________________________ FIRST NAME: ________________________________

MIDDLE NAME: _____________________________ NAME EXTENSION: ___________________________

DATE OF BIRTH: _____________________________ AGE: ________ GENDER: _______________

Belonging to Indigenous Peoples: _______________ Tribe: ______________ Mother Tongue: ____________

Religion: _______________________

Address:

GUARDIANS INFORMATION

Father

Full Name: ________________________________________

Highest Educational Attainment: ___________________________

Employment Status: ____________________________________

Working from Home: ___________________________________

Contact Numbers: ______________________________________

Mother

Full Name: ______________________________________

Highest Educational Attainment: _______________________________

Employment Status: ___________________________________

Working from Home: _____________________________

Contact Numbers: _______________________________

Family Member of 4Ps: ________________________________

HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING

How does your child go to school: Walking Commute School Service Family Owned Vehicle

How many of your household members are studying in School Year 2020-2021?

Kinder: ____ Grade 4: ____ Grade 8: _____ Grade 12: _____

Grade 1: _____ Grade 5: ____ Grade 9: _____ Others: ___________________

Grade 2: _____ Grade 6: ____

Grade 3: _____ Grade 7: ____

Who among the household members can provide instruction support to child’s distance learning?

Parents Grandparents Other

Elder Sibling Extended member None

What devices are available at home the leaner can use for learning? Check all that applies

Cable TV Smartphone Desktop Computer Others

Non – Cable TV Tablet Laptop

Basic Cellphone Radio

Do you have a way to the internet? __________________________________

How do you connect to the internet? Choose all that applies

Mobile Data Computer Shop Own broadband Internet

Other Places (library, barangay and municipal hall, neighbour, relative)

What distance learning modalities do you prefer for your child? Choose all that applies

Online Learning Modular Learning Others

Television Combination of face to face with other modalities

Radio

What are the challenges that may affect your child’s learning process through distance education? Choose all that
applies

Lack of available gadget/equipment Conflict with other activities

Insufficient load/data allowance no or lack of available space for studying

Unstable mobile/internet connection distractions (social media)

Existing health condition others: _________________________________

Difficulty in independent learning _______________________________________