UNHS-JOSE SANVICTORES SR.

NATIONAL SCHOOL-ANNEX
La Purisima, Cagwait, Surigao del Sur
SY 2016 – SY 2019

HOME VISIT FORM

Name of Student : _______________________________________________________

Mother’s Name : _______________________________________________________

Father’s Name : _______________________________________________________

Address : _______________________________________________________

Date of Visit : _______________________________________________________

Problems Discussed

Absences: _____ Tardiness: _____ Grades: _____ Behavior: _____

Others: _________________________________________________________________________________

No. of times visited : Check the appropriate response

____ first visit ____ second visit ____ third visit _______ times

REASONS FOR ABSENCES : Check the appropriate responses

FAMILY
______ Solo parent
______ Financially unstable (walay ikagasto)
______ Provides financial assistance to the family
(tabang ug pangita para sa pamilya)
______ Baby sitting (tabang bantay sa mga manghud)
______ sick family members (may nasakit sa pamilya)
others _____________________________________
_____________________________________

INDIVIDUAL
______ Sickly (permi masakit) ______ Fond of rising late in the morning
______ Peer pressure (barkadista) (dugay mumata)
______ Fond of going elsewhere (Laagan) ______ Addicted to some games
______ Fond of coming home very late at night (naadik ug dula sa bisan unsa nga dula)
(dugay muoli magabie) ______ No study habit (walay tuon-tuon)
others _____________________________________
_____________________________________
COMMUNITY
______ distance of house from school (layo ang balay sa skwelahan)
______ Limited transportation (walay kayo masakyan padulong ug pauli sa skwelahan)
______ distance of house from school
others __________________________________________________________________________

SCHOOL
______ Find difficulty in coping the lessons
(maglisud ug sabot sa klasi)
______ Failing grades (daghan bagsak)
______ doesn’t like some teachers
(may teachers na dili kaganahan)
______ Bullying (sige daug-daugon)
______ Project/Assignments (daghan
project/assignments wala mabuhat)
others _____________________________________
_____________________________________
UNHS-JOSE SANVICTORES SR. NATIONAL SCHOOL-ANNEX
La Purisima, Cagwait, Surigao del Sur
SY 2016 – SY 2019

Reasons for Failing Grades

Insufficient Assignments: _____ Poor Performance : _____ Others: _________________

Insufficient Quizzes : _____ Absences : _____ _________________

Instances Misbehaviors are observed.

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Decision:
______ Go back to school Date of come back ___________________

______ Stop schooling

______ avoid absences

______ avoid coming late

______ avoid cutting classes

______ avoid quarreling

______ avoid misbehaving/bullying

Remark/s:_____________________________________ _____________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

_____________________________ ______________________________
Parent/Guardian’s Signature Teacher’s Signature Over Printed Name

_____________________________
Witness

With pictorials: ______ Without pictorials: ______