Date: ______________________________________

Total Number of Enrolled Learners 1 1 1

Male - ____________________________________
Female - ___________________________________
Total - _____________________________________
4Ps Learners
Male - ____________________________________
Female - ___________________________________
Total - _____________________________________
IPs Learners
Male - ____________________________________
Female - ___________________________________
Total - _____________________________________
Parent/Guardian Info:
No Formal Schooling - _________________________
No Formal Schooling But - ______________________
Elem Level - __________________________________
HS Level - ___________________________________
HS Graduate - _______________________________
After HS Educ - _______________________________
College/Post Grade - __________________________
Household Capacity & Access to DL D1
Kinder - _____________________________________
Grade 1 - ____________________________________
Grade 2 - ____________________________________
Grade 3 - ____________________________________
Grade 4 - ____________________________________
Grade 5 - ____________________________________
Grade 6 - ____________________________________
Grade 7 - ____________________________________
Grade 8 - ____________________________________
Grade 9 - ____________________________________
Grade 10 - ____________________________________
Grade 11 - ____________________________________
Grade 12 - ____________________________________
Others (College) - _____________________________
Household Capacity & Access to DL D2
Parent/Guardian - _____________________________
Grandparents - _____________________________
Extended - _____________________________
Others - _____________________________
None - _____________________________
Able to do IL - _____________________________
Household Capacity & Access to DL D3
Cable TV - ___________________________________
Non Cable TV - ___________________________________
Basic CP - ___________________________________
Smartphone - ___________________________________
Tablet - ___________________________________
Radio- ___________________________________
Desktop- ___________________________________
Laptop - ___________________________________
None- ___________________________________
Others- ___________________________________
With Internet Conn - ___________________________
D5 Internet Connection
Own data - ___________________________________
Own DSL - ____________________________________
Comp. Shop - _________________________________
Other places - _________________________________
Neighbors - ___________________________________
None - _____________________________
Preffered Modalities
Online - _____________________________________
TV - ________________________________________
Radio- ___________________________________
Modular - ___________________________________
Combo - ____________________________________
Others - _____________________________
Challenges
Lack of gadgets - _____________________________
Insu. Load/data - _____________________________
Unstable - ___________________________________
Health Condi - ________________________________
Diffi. IL - ____________________________________
Conflict - ____________________________________
High EC - ____________________________________
Distraction - _________________________________
Others - _____________________________
E. Limited F2F
No. parents - ________________________________
Fear - ______________________________________
Helping - ___________________________________
Transpo - ___________________________________
Armed - ____________________________________
illness - ____________________________________
Chores - ___________________________________
Others- ___________________________________
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