Republic of the Philippines

Department of Education
NATIONAL CAPITAL REGION
SCHOOLS DIVISION OF PASAY CITY
TIMOTEO PAEZ ELEMENTARY SCHOOL
APELO CRUZ ST. MALIBAY PASAY CITY

Address: Apelo Cruz St. Malibay Pasay City

Telephone Number: 8851-0121/ 8519-5201
E-mail Address: 136601@deped.gov.ph
 Republic of the Philippines
Department of Education
NATIONAL CAPITAL REGION
SCHOOLS DIVISION OF PASAY CITY
TIMOTEO PAEZ ELEMENTARY SCHOOL
APELO CRUZ ST. MALIBAY PASAY CITY

HOME VISITATION FORM

Name of Student: _____________________________________________ Year & Section: ________________

Class Adviser: _________________________________________________ Date: ________________________

A. Purpose of Home Visitation:

School Problems (Please encircle)

 Irregular attendance  Poor personal habits

 Prolonged absences  Lack of school materials
 Lack of interest in school work  Physical handicap
 Illness  Behavioural problems
 Others (Please specify) _____________________________

B. Narrative Report/Observation

Instructions: Please write a narrative report in connection with your home visitation. Please include date, time, and place
that the visitation was conducted and give the names of the people (parent/relatives) whom you consulted and discussed
the problems/concern with. Give your recommendation. Use another sheet if needed.

Prepared by: ____________________________ Attested by: _____________________________________

Class Adviser Parent’s/Guardian’s Name & Signature

Address: Apelo Cruz St. Malibay Pasay City

Telephone Number: 8851-0121/ 8519-5201
E-mail Address: 136601@deped.gov.ph