Republic of the Philippines

Department of Education
Region VI- Western Visayas
Division of Sagay City
District of Sagay IX
Colonia Divina Integrated School

SENIOR HIGH SCHOOL PRE-WORK IMMERSION EVALUATION FORM

Name of Student: ………………………………………………………………… Age:
………….
Learner’s Reference Number: ………………………………………………………. Sex: …………
SHS Track: …………………………………………………………………………………………
Strand/Specialization: ……………………………………………………………………………….
Work Immersion Company: …………………………………………………………………………………
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Instruction: Please check the boxes if it is applicable to the student applying for Work Immersion. In
order to pass the evaluation, student should gain at least 3 checks per teacher.
For Specialization Teacher/Trainer:
 Learned the core competencies in his/her chosen specialization.
 Mastered at least the minimum skills required in the chosen field of immersion.
 Can apply his/her learnings in school to the chosen field of work.
 Shows professionalism in doing his/her job.
 Can understand and follow safety procedures while working.

For Class Adviser:

 Can follow simple instructions and can do it with his/her own.
 Can be trustworthy in bringing the name of the school and of the agency.
 With good and acceptable behavior in workplace and public place.
 With no bad behavioral records in school and in community.
 With complete academic and financial clearance.
For Work Immersion Teacher:
 Attended Pre-Immersion Classes
 Resume with White Short Folder & Fastener
 Work Immersion Attire/Personal Protective Equipment
 Parents’ Consent Form
 Physical Check-up
 Proper Hair Cut for boys and no bright hair colors for girls.
 No earrings for boys and proper earrings for girls
 No body tattoos
 Nails are properly cut and no nail polish

Additional Requirements (If needed)

 Medical Certificate  Green/Yellow Card  School ID/Nameplate

………………………………………………… …………………………………………………
Trainer’s Signature Adviser’s Signature

………………………………………………… …………………………………………………
Work Immersion Teacher’s Signature Head Teacher’s Signature

…………………………………………………

Address: Purok Pilar, Brgy Colonia Divina, Sagay City, Negros Occidental
Contact Number: +639959785920/+639392827354
Email Address: coloniadivinais@gmail.com
 Republic of the Philippines
Department of Education
Region VI- Western Visayas
Division of Sagay City
District of Sagay IX
Colonia Divina Integrated School
School Principal’s Signature

Address: Purok Pilar, Brgy Colonia Divina, Sagay City, Negros Occidental
Contact Number: +639959785920/+639392827354
Email Address: coloniadivinais@gmail.com