INDIVIDUAL INQUIRY PROFILE OF ____Single Mom / Dad

STUDENTS
A. PERSONAL / BASIC INFORMATION
8. Family's Economic Status: * INSERT
LRN: * ____Below Php 10,000 1 BY 1
___________________ ____Php 10,001 - 20,000 PHOTO
____Php 20,001 - 30,000
Name of Student / Pupil: * ____Php 30,001 - 40,000
LAST NAME, FIRST NAME, MIDDLE NAME ____Php 40,001 - 50,000
____Above 50,001
Your answer_____________________________
9. Are you a member of 4Ps? *
Gender: * ____Yes
____Male ____No
____Female
____Birthdate: * 10. Whom are you living with at present? *
YYYY-MM-DD (2015-06-01) ____Both parents
____Guardian / Relative
Your answer_____________________ ____Non-Relative
Other : ___________
Age: *

Your answer 11. Who is closer to you? *

Address: *
Your answer_____________________________
Religion: *
Your answer_____________________
School: LABIT WEST ELEMENTARY SCHOOL
B. FAMILY BACKGROUND
1. Father's Name: *
Your answer_____________________________
2. Father's Work: *
Your answer_____________________________
3. Mother's Name: *
Your answer_____________________________
4. Mother's Work: *
Your answer_____________________________
5. Guardian's Name: *
In the absence of parents
Your answer_____________________________
6. Guardian's Work: *
In the absence of parents
Your answer_____________________________
7. Marital Status of Parents: *
____Married / Living Together
____Unmarried / Live-in
____Separated / Annulled
____Mother
____Father
____Grandparents
Other : _________
12. Whom did you grow up with? *
____Parent/s
____Grandparents
____Relatives
Other : ________________
C. SOCIO-EMOTIONAL ATTRIBUTES
1. Which of the following do you enjoy doing? *
____Singing
____Dancing
____Playing computer games
____Writing
____Reading
____Cleaning the house
____Drawing / sketching
____Cooking
____Watching movies / television
____Texting and surfing the net
____Driving (motorcycle, bike, etc.)
Other: _______________________
2. What type of a person are you? *
____Introvert / shy / loner
____Extrovert / active / outgoing
3. How would you describe your childhood days? *
____Happy / exciting
____Sad / traumatic
4. Who do you enjoy / prefer as company? *
____Family
 ____Friends
____Alone
Other : ________________

5. Where do you enjoy staying? *

____Home D. NARRATIVE
____School
Narrative of the Teacher In-Charge
Other :
about the Learner's Significant
6. What type of friends do you prefer? * Info/Characteristics: *
____Happy and loud (personal Aspect, Family background and
____Quiet and shy Learner's problem/concern)
____Carefree Your answer:
____Studious ____________________________________________
Other : ____________________________________________
____________________________________________
7. Have you ever been bullied? * ____________________________________________
____Yes ____________________________________________
____No ______________
8. For what reason you were bullied? *
Your answer:
____________________________________________
__________________________________
Grade of the Learner: 4-DAHLIA

9. Do you have any record of bullying your peers or

others? * Updated by: *
____Yes
____No
FLORENCE D. FAJARDO
10. State reason for bullying others. * Class Adviser
Your answer:
____________________________________________
__________________________________

11. Are the criticisms and suggestions of others

important to you? *
____Yes
____No
12. How often do you pray? *
____Once a day
____Twice a day
____Not at all
Other :