Adopted form DepEd SY 2022-2023

(Enclosure No. 4 to DepEd Order No. 007, s. 2020)

LEARNER SURVEY FORM

THIS FORM IS NOT FOR SALE

Instructions:
1. This survey shall be answered by the parent/guardian of the learner.
2. Please read the questions carefully and fill all applicable spaces and write your answers legibly in CAPITAL letters. For items not
applicable, write N/A.
3. For questions/clarification, please ask for the assistance of the teacher/person-in-charge.

A1. Last Name ____________________________________________________________________

A2. First Name ____________________________________________________________________

A3. Middle Name ____________________________________________________________________

A5. EXTENSION NAME e.g. Jr., III (If applicable) ___________________________________

For Learners with Special Education Needs

A6. Date of Birth ___________________________
A12. Does the learner have special education needs?

Yes No
A7. Age _________ A8. Sex Male Female
A13. If yes, please specify:
A9. Belonging to Indigenous Peoples (IP) Yes No
____________________________________________
Community/Indigenous Cultural Community
A14. Do you have any assistive technology devices available at home? (i.e. screen
A10. If yes, please specify: _________________
reader, braille, DAISY)
A11. Mother Tongue: _________________
Yes No

A15. If yes, please specify: _______________________________

Address
A16. House Number and Street A17 Barangay
_________________________________________________________________________________________________________
A18. City/Municipality A19. Province A20. Region
_________________________________________________________________________________________________________

C. PARENT/GUARDIAN INFORMATION
Father Mother Guardian

C1. Full Name (surname, full name, middle name) C7. Full Name (surname, full name, middle name) C13. Full Name (surname, full name, middle name)

C2. Highest Education Attainment C8. Highest Education Attainment C14. Highest Education Attainment
Elementary graduate Elementary graduate Elementary graduate

High School graduate High School graduate High School graduate

College graduate College graduate College graduate

Vocational Vocational Vocational

Master’s Doctorate degree Master’s Doctorate degree Master’s Doctorate degree

Did not attend school Did not attend school Did not attend school

C3. Employment Status C9. Employment Status C15. Employment Status

Full time Full time Full time

Part Time Part Time Part Time

Self-employed (i.e. family business) Self-employed (i.e. family business) Self-employed ( i.e. family business)

Unemployed due to ECQ Unemployed due to ECQ Unemployed due to ECQ

Not Working Not Working Not Working

C4. working from home due to ECQ? C10. working from home due to ECQ? C10. working from home due to ECQ?
Yes No Yes No Yes No

C5. Contact number/s (cellphone/telephone) C5. Contact number/s (cellphone/telephone) C5. Contact number/s (cellphone/telephone)
Cellphone No: Cellphone No: Cellphone No:
Telephone No: Telephone No: Telephone No:

D2. How many of your household members (including the enrollee) are D3. Who among the household members can provide instructional
child’s studying in School Year 2021-2022? Please specify each. support to the distance learning? Choose all that applies.
Kinder ______ Grade 4 _______ Grade 8 __________ Grade 12 _______ parents/ guardians others (tutor, house helper)
Grade 1 ______ Grade 5 _______ Grade 9 __________ others _______ elder siblings none
Grade 2 ______ Grade 6 _______ Grade 10 __________ (i.e. college, vocational, etc.) grandparents able to do independent learning
1
 Grade 3 ______ Grade 7 _______ Grade 11__________ extended members of the family
D4. What devices are available at home that the D5. Do you have a way to D6. How do you connect to the internet? Choose all that
Learner can use for learning? Check all that applies. Connect to the internet? applies.

cable TV radio Yes own mobile data

non-cable TV desktop computer own broadband internet (DSL, wireless fiber, satellite
basic cellphone laptop No computer shop
smartphone none (If NO, proceed to D7) other places outside the home with internet connection
tablet others: _____ (library, barangay/ municipal hall, neighbor, relatives)
other: _____________________

D7. What are the challenges that may affect your child’s learning process through distance education? Choose all that applies.

lack of available gadgets/ equipment conflict with other activities (i.e., house chores)
insufficient load/ data allowance high electrical consumption
unstable mobile/ internet connection distractions (i.e. social media, noise from community neighbor)
existing health condition/s others: ______________________
difficulty in independent learning

D8. What is your preferred Individual Learning Packet (Mode of Delivery) for your child?

Purely Online Purely Offline

D9. How do you prefer to access your child’s modules?

soft copy hard copy

(modules are uploaded in MS Teams) (to be picked-up by parents/guardians at the guardhouse by
appointment with concerned teacher)

I hereby certify that the above information given are true and correct to the best of my knowledge and I allow WMSU ILS High School Department use my child’s
details to create and/or update his/her learner profile in the Learner Information System, the information herein shall be treated as confidential with the Data
privacy Act of 2012.

____________________________________________ _____________________
Signature Over Printed Name of Parent/Guardian Date

____________________________________________
Contact Number

- - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - -- - - - - -

To be filled up by the Class Adviser.

DATE OF FIRST ATTENDANCE / / /

(Month/Day/Year)

Grade Level ______________________________ Track (for SHS) ___________________