Republic of the Philippines

Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OF SAN JOSE DEL MONTE CITY
DANIEL A. AVENA ELEMENTARY SCHOOL
BRGY. DULONG BAYAN

LEARNERS’ TRACKING FORM

A. STUDENT FAMILY BACKGROUND QUESTIONNAIRE
1. Student’s Name: ___________________________________________________________________ Age: ______
LRN: ________________________________________________ Sex: ______
Address: __________________________________________________________________________________________
Number Street Municipality/City/Province
Nationality: ______________________ Religion: ___________________________
Date of Birth: (mm/dd/yy) _________________ Place of Birth: __________________ Ethnic Affiliation: ________
Birth Registered? Yes________ No________
2. Has student dropped out of school? Yes________ No________
If yes, for how long? _________ What reason: ________________________________________
3. Distance from home to school: ____ km. Means of transportation to school:___ car ___ tricycle ___ jeepney
___ bicycle ___ others: _____________
4. Has any member of the family ever dropped out of school? Yes_____ No_____
5. Is the student receiving any type of financial assistance to attend school? Yes_____ No_____
If yes, from what source______________________________________
6. With whom does the student live? Both parents___ Mother only ___ Father only ___ Others____________
7 Who helps the student live? Both parents___ Mother only ___ Father only ___ Others____________
8. Family Background
Information Father ____living ____deceased Mother ____living ____deceased
Name:
Age:
Address:
Nationality:
Religion:
Language/s Spoken:

9. Parental Marital Status: ___Married ___Live-in ___Annulled ___Separated

10. List all members of the household including those who have migrated. Specify the information needed.
Sex Relationship Education
Name of Household Member Age Occupation
(Male Female) to Student (Enrolled/ Completed/ Degree

11. Is the family a member of any community development organization?____Yes ____No

If yes, (Pls. specify) ___________________________________________
12. Monthly Household Income ____Below P1, 000 ____P2, 500 - P5, 000 ____P8, 000- P15, 000
____P1, 000 – P2, 500 ____P5, 001- P8, 000 ____over 15, 000
13. Information about the family dwelling
 The family: _____owns house and lot _____rents a house Others (Pls. specify) _______________
 Type of house: _____concrete ______semi-concrete Others (Pls. specify) _______________
 Type of toilet: ____flush ____pit ____no toilet
 Source of water supply: ____faucet/ tap Others (Pls. specify)_____________________
 Power source: ____electricity ____kerosene Others (Pls. specify) ______________
14. Which of the following are available at home?___t.v. ___newspaper ___magazines
___radio ___books Others (pls. specify) ______________

Daniel A. Avena Elementary School

School ID: 107153
Brgy. Dulong Bayan, San Jose del Monte City 3023
Official E-Mail: 107153.sjdmc@deped.gov.ph
Official Website: depeddulongbayanes.weebly.com
Telephone Number: 044-815-1831
 Republic of the Philippines
Department of Education
REGION III-CENTRAL LUZON
SCHOOLS DIVISION OF SAN JOSE DEL MONTE CITY
DANIEL A. AVENA ELEMENTARY SCHOOL
BRGY. DULONG BAYAN

B. STUDENT EDUCATIONAL HISTORY

Grade/Section School School Year Adviser
Kinder -
One -
Two -
Three -
Four -
Five -
Six -

C. HEALTH AND NUTRITION PROFILE

Nutritional Status
Grade/Section Height (cm) Weight (kg)
Wasted Normal Obese
Kinder -
One -
Two -
Three -
Four -
Five -
Six -

D. COMMON DISEASE/ ILLNESS INCURRED WITHIN THE YEAR

Grade/Section School Year Disease/ Illness No. of Days Absent
Kinder -
One -
Two -
Three -
Four -
Five -
Six -

E. IMMUNIZATIONS (Check if vaccinated already)

BCG Diphtheria Tetanus Polio Measles Whooping Cough Psoriasis Hepa B

F. ABSENTEEISM AND DROP-OUT PROFILE

Grade/Section School Year No. of Days Absent Reason % Attendance Remarks
Kinder -
One -
Two -
Three -
Four -
Five -
Six -

School Year Ever Dropped out? How Long? Reason

(yes/no)

Daniel A. Avena Elementary School

School ID: 107153
Brgy. Dulong Bayan, San Jose del Monte City 3023
Official E-Mail: 107153.sjdmc@deped.gov.ph
Official Website: depeddulongbayanes.weebly.com
Telephone Number: 044-815-1831