Republic of the Philippines

Department of Education
CORDILLERA ADMINISTRATIVE REGION
Schools Division of Ifugao
Alfonso Lista District

EASTERN POTIA NATIONAL HIGH SCHOOL

San Jose, Alfonso Lista, Ifugao

STUDENT'S FEEDBACK FORM

Name of Student: ________________________________ Quarter: ___________

School: ____________________________________ Week: ____________
District: _________________

Check the box for your appropriate/honest answer.

YES NO
1. Did the video/module help you understand the lesson?
2. Were you able to follow the instructions in all the parts of the
printed module?
3. Were you able to understand and accomplish all the activities?
4. Were you guided by your parent/guardian/siblings in accomplishing
the activities?
5. Did you ask questions/clarifications/queries to your teacher through
Text/Call/Messenger?
6. Did you receive any answer from your teacher?
7. What was your score in the post assessment? Indicate the score
over the item. (Example: 8/10)
8. Others (Write any other comments/feedbacks/suggestions)

___________________________
Signature of student/pupil
Republic of the Philippines
Department of Education
 CORDILLERA ADMINISTRATIVE REGION
Schools Division of Ifugao
Alfonso Lista District

EASTERN POTIA NATIONAL HIGH SCHOOL

San Jose, Alfonso Lista, Ifugao

PARENT’S FEEDBACK FORM

Name of Parent: ________________________________ Quarter: ___________

School: ____________________________________ Week: ____________
District: _________________

Check the box for your appropriate/honest answer.

YES NO
1. Did you find an instruction in the learning package?
2. Did you read and follow the instructions carefully?
3. Were the instructions clear?
4. Did you guide/assist your child based on the instructions given?
5. Did you ask questions/clarifications/queries to the teacher of your
child through Text/Call/Messenger?
6. Did you receive any answers from the teacher?
7. Were you clarified of your queries/questions?
8. Others (Write any other comments/feedbacks/suggestions)

_________________________________________
Signature over printed name of parent/guardian

Republic of the Philippines

Department of Education
CORDILLERA ADMINISTRATIVE REGION
Schools Division of Ifugao
 Alfonso Lista District

EASTERN POTIA NATIONAL HIGH SCHOOL

San Jose, Alfonso Lista, Ifugao

Republic of the Philippines

Department of Education
CORDILLERA ADMINISTRATIVE REGION
Schools Division of Ifugao
 Alfonso Lista District
EASTERN POTIA NATIONAL HIGH SCHOOL
San Jose, Alfonso Lista, Ifugao
PILOT TESTING ON MODULAR DISTANCE LEARNING
List of Parents and Students
English 7
First Quarter-Week 1
Name of Parent Name of Child Date Received Date Returned Signature
1. Calumpit. Jane A.
2. Castro, Mark Dave T.
3. Cluramo, Frances Xyrin G.
4. Dela Cruz, Chelza Mae
5. Dela Merced, Antonio Jr.
6. Domingo, Princess Irish A.
7. Hoggang, Gracious O.
8. Juan, Tefanie-Jean A.
9. Kindipan, Lhender Raye B.
10. Lungob, Ria-yain B.
11. Magtuto, Sunshine
12. Marinay, Ariel
13. Martinez, Therdy A.
14. Medina, Rimar B.
15. Monchig, Aelyza M.
16. Reyes, Mark Paul
17. Sabado, Mery Angel M.
18. Sabado, Sanny L.
19. Sagun, Kent Denver B.
20. Sagun, Shaina Reine P.
21. Segundo, John Loid V.

Prepared by: Noted:

GEMELYNE T. DUMYA-AS LILIA P. BAYAWON

Subject Teacher School Head