Psychosocial Support for Face-to-Face Learning Modality Evaluation Form Learners' Response Te

This templates aims to collate and organize the responses of learners in the Psychosocial Support Evaluation Form (Pagsusuri
Pagbabalik Eskwela). This is primarily for the use of the TEACHERS who are expected to facilitate the psychosocial support a
evaluation form to learners (kinder teachers shall complete the form for their learners through a checklist format). This should b
to the SCHOOL HEAD within 5 days after the administration of the evalution forms to learners (i.e. note that there are 3

You may refer to OUA MEMO 00-1121-0125 (Dissemination of Psychosocial Activity Pack for Schools Participating in the Pilot
Face-to-Face Learnin Modality) for the details about the Psychosocial Support Acitivty Pack (Guidelines and Evaluation Form)

Intructions:
a) Download this form. DO NOT EDIT DIRECTLY ON THIS GOOGLE SHEET. Secure your own copy.
b) Collect learners' responses from the psychosocial evaluation form.
c) Encode learners' responses according to your grade level.
d) Submit the encoded and collated learners' responses to your School Head for submission.
e) If there are concerns regarding the template, contact DRRMS-MHPSS through e-mail at drrms+mhpss@deped.gov.ph
orm Learners' Response Template
Evaluation Form (Pagsusuri sa Sikososyal para sa
e the psychosocial support activities and administer this
ecklist format). This should be completed and submitted
rs (i.e. note that there are 3 schedules for administration).

ools Participating in the Pilot Implementation of the Limited

elines and Evaluation Form)

opy.

+mhpss@deped.gov.ph
 Napapanatili
May mga
Nagsasabi o Huminingi Nag-iisip kaming ligtas
guro at Natutuko
nagbabahagi Pinaoak ako ng ako ng mula sa epekto Proprotekta
kamag-aral Naipap y ko ang Nakatu
Date of Natutukoy ako ng aking alma ko tulong sa mga ng mga hindi han ko ang
akong akita ko mga May tulong
ko ang mga iniisip o ang aking mga paraan inaasahang aking sarili
Evaluatio handang
aking mga nararamdam aking kamag- para
ang nararamd Masaya gana sa
pangyayari, mula sa
n Form Schoo makinig aking aman o akong akong aking
nararamda an sa aking sarili aral, o lutasin gaya ng pagkakasak
Grade kapag gusto mga pinagdad makabali pumas pag-
was Region Division School ID l Level
Learners' Name LRN kong
man tulad mga kamag- jkapag guro, o ang mga
kalakas aan ng k sa in- ok muli aaral
sakuna. Sa it o nag-
Administe Name ng saya, aral, ako'y kaibigan, o problema pamamagitan iingat mula
sabihin o an at aking person sa ng in-
lungkot, kaibigan, takot, pa,ilya o ng mga sa mga
red to ibahagi ang
galit, pagod guro, galit, o kapag pagsubok
kakaya mga na klase. paarala person
ginagawang hindi
Learners aking mga han sa kamag- n na
at iba pa. magulang o malung nahihirapa na aking paghahanda at inaasahang
iniisip o paralan aral o ng klase
tagapangala kot. n ako sa kinakahar pag-iingat ng pangyayari.
nararamda iba.
ga pag-aaral. ap. aming
man
paaralan.

BARDOQUILLO,XAVIER JOHN,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 MANTICAJON
132836160002 5 3 4 4 3 4 5 3 4 4 3 5 5
CONSUMO,EARL LORENZ,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 TUSAN
130879150038 5 5 4 5 5 4 5 5 5 5 4 5 5

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 CORTINA,JULIUS, II ALEGRE 132836160026 4 3 4 5 5 5 1 4 4 4 4 5 5

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 CURAY,RICHARD, PLANIA 132836140124 4 5 4 3 2 5 5 5 4 4 4 5 5

DALOGDOGAN,GAILYMER,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 TALIMAN
132836160003 5 3 1 3 3 3 3 5 5 5 5 3 3

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 DORDAS,RHAVEN, REQUINA 132844160098 5 5 4 4 3 4 5 5 5 5 4 4 5

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 MURIO,REYMARK, DIZON 132836150037 5 5 5 4 1 5 4 5 5 5 5 5 5

OBERES,JOHN DAVE,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 REPOJIO
132836160044 5 4 2 3 5 4 3 4 5 3 1 3 4
OBERES,JOHN STEVE,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 REPOJIO
132836160043 5 4 4 4 3 4 4 4 4 4 4 4 4
PENADOS,JOHN DOMER,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 HOYOS
132836160009 4 3 5 3 2 1 4 2 5 5 5 4 3

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 PORLAS,JOALI, AMOGUIS 406036160035 5 4 4 4 3 4 4 4 4 4 4 4 4

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 POSTANES,JANJO, ANDREE 132836160011 3 5 4 5 5 5 4 5 5 5 5 5 5

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 SIAREZ,STEEVE NICOLEIGH, - 132836150063 5 4 5 5 4 5 5 4 5 4 4 5 5

TOROBA,STEPHEN JAY,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 ORTIZ
132836150041 5 4 5 5 5 4 4 3 5 4 4 5 2

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 YTAC,PRINCE ROM, DUA 132836160033 5 4 4 4 5 3 5 3 5 4 5 4 3

<=== TOTAL MALE 15

ANCASAN,STEFANY,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 ABEDEJOS
132836160013 5 4 5 5 5 5 5 5 5 5 5 5 5
ANDUHOYAN,JEMAICA,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 ATENDIDO
132836160034 5 5 5 5 5 5 5 5 5 5 5 5 5
 AVANCEÑA,MARIA
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 KATHEREN, COSTAN
132836160036 5 2 4 5 5 5 5 5 5 5 5 5 5

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 BELBERTO,LEA, DIAZ 214516160013 5 4 5 4 5 4 5 4 5 5 5 4 5

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 CAPILE,CRISTINE, GARCIA 132836160038 5 4 5 5 5 5 5 5 5 5 5 5 5

CRUIZ,KIZZA TRISHA,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 GALUDO
132836160046 4 5 5 5 4 4 4 3 5 5 5 4 4

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 DEJARME,MYCA, BETARMOS 120915160002 4 5 3 4 4 5 4 5 5 2 4 4 4

DINALAGAN,CHIEZELLE MAE,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 LUAGUE
129651160066 5 4 5 4 5 4 4 4 5 4 5 4 5
GOPIO,DENISE KRISHA,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 GALUDO
132836160045 5 3 5 4 5 5 2 5 5 5 5 4 4
PADILLO,KEESHA MAE,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 MILLADAS
132836160040 5 4 4 1 4 3 3 5 5 5 5 5 5

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 PIANO,CHERISH, BAGON 132838160056 4 4 4 4 4 4 5 4 5 4 5 5 5

8/22/2023 CARAGA BISLIG CITY 132837 MNES 6 SALAS,SHANAIAH, GOMEZ 132836160022 4 4 4 4 4 4 5 4 5 4 5 5 5

TORRES,PHOEBE MYELLE,
8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 VILLACERAN
132836160041 4 4 4 3 5 5 5 5 5 5 4 4 5

8/22/2022 CARAGA BISLIG CITY 132836 MNES 6 TRIMIDAL,JELOH, AVILA 406040160038 5 5 5 5 5 5 5 5 5 5 5 5 4

<=== TOTAL FEMALE 14