FATHER SATURNINO URIOS UNIVERSITY

College Guidance Center

Butuan City

STUDENT INDIVIDUAL INVENTORY FORM

School Year 2021 -2022

Welcome to the FSUU Guidance Center!

The purpose of the Student Individual Inventory Form is to gain necessary data from
the students to aid them toward self-knowledge and self-realization.
Kindly complete this form with your information to help you and your counselor in
planning a course of action. Any information that you provide are strictly confidential.
Status: College Course: BS Nursing
Year/Grade Level: Second Year

A. PERSONAL INFORMATION
Name: Cloma, Therese Yzabel B Nickname: Yza Sex: F Age: 019
Civil Status: Single Religion: Roman Catholic Date of Birth: 10-10-2001
Nationality: Filipino
City Address: Butuan City Mobile#: 09164853833
Home Address: Purook 4 Upper Doongan
Birth Rank: Eldest Number of Sisters: 1 Number of Brothers: 1 Blood Type:

Height: 152 Weight: 66

In case of emergency, please notify: Meriam B. Cloma Relationship: Mother
Address: Purook 4 Upper Doongan Butuan City Mobile#: 09126146225

As a student, I am living with: (please select) parents Others(please specify) Type here

Language spoken at home: Bisaya Language most fluent at: Bisaya

HEALTH CONDITIONS

Disabilities/Impairments: None Illnesses: Asthma

Accidents Experienced: none Operations Experienced: None

B. FAMILY BACKGROUND
Father Mother Guardian
(Mark with + if deceased) (Mark with + if deceased) (if not living with parents)
Name Narciso M. Cloma J.r Meriam B. Cloma
Age 48 50 Type here
Address Purook 4 Upper Doongan Butuan
PurookCity
4 Upper Doongan Butuan
Type City
here
Phone No. none 09126146225 Type here
Religion Roman Catholic Romaan Catholic Type here
Highest College Degree Masteral Degree Type here
Educational
Attainment
Occupation None Government Employee Type here
Employer none BIR Type here
Estimated none 40000 Type here
Monthly Income

Marital Status of Parents Living together

Please name below siblings from eldest to youngest, include yourself.

Name of Siblings School Age
Meryanne Junn B. Cloma Agusan National High School Type here
Raphael Jun B. Cloma Doongan Elementary School Type here
Full name Type here Type here
Full name Type here Type here
Full name Type here Type here
Full name Type here Type here
Full name Type here Type here
Full name Type here Type here
Full name Type here Type here
Full name Type here Type here
Full name Type here Type here

B. EDUCATIONAL BACKGROUND
School Address Year
Graduated
/Attended
Pre-School Rainbow of Angels Learning CenterSouth
Incorporated
Montilla Blvd. Butuan City Type here
Elementary Butuan Centraal Elementary SchoolA.D Curato St, Butuan City 2014-2015
High School Agusan National High School A.D Curato St, Butuan City 2017-2018
College Father Saturnino Urios University San Fransisco St. Butuan City 2020
Junior High Agusan National High School A.D Curato St, Butuan City 2017-2018
Senior High Father Saturnino Urios University- B.P
SanPueblos
Fransisco
-SHS
St. Butuan City 2019-2020
School Last San Fransisco St. Butuan City San Fransisco St. Butuan City 2019-2020
Attended

Easiest subject: English

Most difficult subject: BbioChemistry
Subjects with high grades/ what grades: Type here
Awards/Honors Received: Type here

Membership in Organizations (In School/Outside School)

Name of Organization Position/Title
Type here Type here
Type here Type here
Type here Type here
Type here Type here

SELF-EVALUATION
Friends (in School): Trisha, Mikaela, Mizpah, Keven, Joan, Andre, Kenneth, Raychel
(outside School): All written above
Special Interests: cooking, baking
Special Skills/Talents: Critical thinking, singing
Hobbies/Recreational Activities: Badminton
Ambitions/Goals: To become a person God wants me to be
Guiding Principle in Life/Motto: You are more than what people thinks about you.
Characteristics that describe you best: Defender
Present Concerns/Problems: none
Present Fears: To lose someone important to me
I need to improve my...
✘ self-confidence
✘ time management
proper etiquette
relationship w/ opposite sex
✘ relationship w/ siblings
✘ relationship w/ parents
others, specify Type here
social skills
✘ personal appearance
study skills/habits
✘ stress management
✘ ability to handle emotions
ability to deal with conflict
relationship with classmates
relationship with friends
relationship with teachers
decision making skills
work values/habits

Have you consulted a counselor before? Yes ✘ No

If yes, when? Type here For what? Type here
If no, why? I'm shy
How can the counselor help you with your concern?
Type here

DATA PRIVACY CONSENT

By accepting this Data Privacy Statement, I grant my free, voluntary and unconditional
consent to the collection and processing of all Personal Data to the information system of
Father Saturnino Urios University Guidance Center by whatever means in accordance with
Republic Act (R.A.) 10173, otherwise known as the “Data Privacy Act of 2012” of the Republic
of the Philippines, including its Implementing Rules and Regulations (IRR)as well as all other
guidelines and issuances by the National Privacy Commission (NPC). I also consent to the
following:
1. The FSUU Guidance Center may collect personal data during my application for admission
purposes.
2. My personal information can be accessed and used only by authorized personnel and
officials connected to the University for legitimate purposes only.
3. The FSUU Guidance Center may share or disclose some of my personal information to
others in its process to deliver necessary services for the stakeholders and the institution,
including but not limited to:
a. Sharing information for accreditation purposes (PAASCU, CHED)
b. Conducting research or surveys for purposes of institutional development
c. All guidance and counseling-related functions and services
d. Other legitimate processes of the University.

✘ I hereby declare that all of the information provided during my application are true
and accurate to the best of my knowledge. I hereby attest to the completeness and
accuracy of all the information that I have provided .