GRADE 1- _____________________ DATE: ____________

ENROLLMENT: MALE= _____ FEMALE= _______ TOTAL= _______

C.2 FATHER/MOTHER/ GUARDIAN Highest Educational Attainment

HEA -1 HEA -2 HEA -3 HEA -4 HEA -5 HEA -6 HEA -7 TOTAL

GRADE 1-
LEGEND:
HEA-1 No formal schooling
HEA-2 No formal schooling but able to read and write
HEA-3 Elementary level
HEA-4 Elementary Graduate
HEA-5 High School Level
HEA-6 High School Graduate
HEA-7 After High School Education (College / Post Grad) or Technical/Vocational

C10. Is your family a beneficiary of 4Ps?

YES NO TOTAL
GRADE 1-

D.1 How many of your household members (including the enrollee) are studying in school year 2021-2022? please specify
each.

KINDE G- G- G- G- G- G- G- G- G- G- G- G- COLLEGE,
VOCATIONAL
R 1 2 3 4 5 6 7 8 9 10 11 12 TOTAL
GRADE 1-

D2. Who among the household members can provide instructional support to the child’s distance learning? Choose all that
applies.

HM-1 HM-2 HM-3 HM-4 HM-5 HM-6 HM-7 TOTAL

LEGEND:
HM-1 parents/ guardians
HM-2 elder siblings
HM-3 grandparents
HM-4 extended members of the family
HM-5 others (tutor, house helper)
HM-6 none
HM-7 able to do independent learning

D3. What devices are available at home that the learner can use for learning? Check all that applies.

DA-1 DA-2 DA-3 DA-4 DA-5 DA-6 DA-7 DA-8 DA-9 DA-10 TOTAL
GRADE 1-
LEGEND:
DA-1 cable TV
DA-2 non-cable TV
DA-3 basic cellphone
DA-4 Smartphone
DA-5 Tablet
DA-6 radio
DA-7 desktop computer
DA-8 laptop
DA-9 NONE
DA-10 others:

D4. Is there an internet signal in your area?

YES NO TOTAL
GRADE 1-
 D5. How do you connect to the internet? Choose all that applies.

IC-1 IC-2 IC-3 IC-4 IC-5 IC-6 TOTAL

GRADE 1-

LEGEND:
IC-1 own mobile data
IC-2 own broadband internet (DSL, wireless fiber, satellite
IC-3 computer shop
IC-4 other places outside the home with internet connection (library, barangay/
municipal hall, neighbor, relatives
IC-5 None

D6. What distance learning modality/ies do you prefer for your child? Choose all that applies.

DLM-1 DLM-2 DLM-3 DLM-4 DLM-5 DLM-6 DLM-7 TOTAL

GRADE 1-

LEGEND:
DLM-1 online learning
DLM-2 Televisio
DLM-3 Radio
DLM-4 modular learning Printed
DLM-5 Modular Learning Digital
DLM-6 combination of face to face with other modalities
DLM-7 OTHERS

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

CH- CH- CH- CH- CH- CH- CH- CH- CH- TOTAL
1 2 3 4 5 6 7 8 9
Grade 1-
LEGEND:
CH-1 lack of available gadgets/ equipment
CH-1 insufficient load/ data allowance
CH-3 unstable mobile/ internet connection
CH-4 existing health condition/s
CH-5 existing health condition/s
CH-6 conflict with other activities (i.e., house chores)
CH-7 high electrical consumption
CH-8 distractions (i.e., social media, noise from community/neighbor)
CH-9 others:

E1. In case limited face to face classes will be allowed, are you willing to allow your child/ children to participate?

YES NO TOTAL
GRADE 1-
E.2 If the answer is no, please select only 1 major consideration or state specific reason

MC-1 MC-2 MC-3 MC-4 MC-5 MC-6 MC-7 TOTAL

GRADE 1-
LEGEND
MC-1 Fear of Getting Infected of Corona Virus
MC-2 Existing Illness or health related concerns
MC-3 Presence of Arm Conflict
MC-4 Limited or no available transportation from home to school and vice versa
MC-5 Helping in household chores
MC-6 Helping Family business or working
MC-7 Others, specify