Republic of the Philippines

DR. EMILIO B. ESPINOSA, SR. MEMORIAL

STATE COLLEGE OF AGRICULTURE AND TECHNOLOGY Attach 2x2 photo with
white background and
Guidance and Counseling Office nametag
www.debesmscat.edu.ph ǀ Cabitan, Mandaon, Masbate

INDIVIDUAL STUDENT INVENTORY FORM

GENERAL INSTRUCTION: Fill out all the required information, or do

not leave an item blank. If it’s not applicable, indicate N/A. Erasures on
this form are not allowed. Use a black ball pen only. All your answers
will be treated with the utmost confidentiality in compliance with the Data
Privacy Act of 2012.
I. PERSONAL BACKGROUND

________________________________________________________________________________________________________________
(Last Name) Put extension if any, i.e., Jr., III (First Name) (Middle Name) (Maiden Name) for married woman
Age: Civil Status: Date of Birth: Religion:
Sex: Nationality: Place of Birth: Cellphone No:
Email Address: Name of Boarding House:
Home/Permanent Address:
Skills, Hobbies, Interests:

II. FAMILY BACKGROUND

Parents Records Father Mother

Complete Name Last Name: _____________________________ Last Name: _____________________________
First Name: _____________________________ First Name: _____________________________
Middle Name: ___________________________ Middle Name: ___________________________
Date of Birth
Highest Educational Attainment
Occupation
Cellphone Number
*Note: Write (+) for deceased.
A. Parents: (Please check) C. Name of Guardian: _____________________________
___ Living Together ___ Temporarily Separated D. Name of Contact Person in Case of Emergency:
___ Permanently Separated ___ Father (OFW) ____________________________________________
___ Marriage Annulled/ Legally Separated ___ Mother (OFW) E. Closest Member of the Family ( ) Father ( ) Mother
___ Father with another partner ___ Mother with another partner ( ) Brother ( ) Sister
B. Please write your siblings from eldest to youngest, including yourself.

Name of Siblings Age Civil Status

III. EDUCATIONAL BACKGROUND

School Last Attended Inclusive Years of Attendance

Elementary
Junior High School
Senior High School
Tertiary (if already obtained
Bachelor’s degree from another school

FM-GCO-01 00 01-23-23
IV. HEALTH STATUS: (Please check your answer.)
( ) Physically Fit ( ) Pregnant ( ) Physically Challenged (Person with Disability) Please indicate the type of disability/impairment. _______

V. SOCIAL INVOLVEMENT
A. In School (During High School/ College)
Name of Organization Position in the Organization

B. Outside School (Like Church, Community, etc.)

Name of Organization Position in the Organization

I, at this moment, certify that the above information is accurate and correct.

___________________________________________
(Signature over Printed Name of Student)

PRE-COUNSELING INTERVIEW

1. Why did you choose DEBESMSCAT as your college institution?

2. Why did you decide to enroll here?

3. What are your academic goals?

4. Who will finance your study?

5. How is your relationship with your family? With your siblings?

6. Do you have a peer group (barkada) here in school?

What activities do you like to do with your peer group?

7. How do you deal with challenges? In times of hardship, who do you usually open up to?

8. What are the important issues for you right now? (e. g. family, friends, health, academics, etc.) Elaborate your answer.

Checked by: ____________________________________

Date Received the ISI Form: _______________________

FM-GCO-01 00 01-23-23