HOME VISITATION FORM

S. Y: 2019- 2020

Picture
Name of Student: ________________________________________ LRN: ____________________ Grade Level/Section: ___________________
(1 x 1)
Address: ________________________________ Birthday: ___________________ Gender: _______ Age: ______ Contact: ________________
Student’s
Name of Reasons/causes of Absences __ Parent/Guardian’s
Date of Visit Remarks/Agreement Signature Over
Parent/Guardian for Dropping Out __ Signature Over Printed
Printed

o Sickness o Truancy
o Home Chores o Indifference
1st Visit o Employment o Classroom Atmosphere
o Family Problems o Distance of Home ____________
o Lock of Interest o Hunger/Malnutrition
____________ o Parent attitude o Had to take care of siblings ____________
__________ towards schooling o Teacher Factor ____________ _____________ _____________

o Sickness o Truancy
o Home Chores o Indifference
2nd Visit o Employment o Classroom Atmosphere
____________
o Family Problems o Distance of Home
____________
o Lock of Interest o Hunger/Malnutrition ____________
__________ o Parent attitude o Had to take care of siblings ______________ ______________
towards schooling o Teacher Factor ____________

Noted: Prepared by:

______________________________ ________________________
Principal/Guidance Councelor Teacher