Anecdotal Record: Concepcion Elementaty School

Republic of the Philippines
Department of Education
Region III
Division of Nueva Ecija
District of Cabiao
CONCEPCION ELEMENTATY SCHOOL
ANECDOTAL RECORD
Name: ________________________________ Nickname: __________________

Address: __________________________________________________________________
Date of Birth: ______________________ Age: ____________ Sex: ____________
Grade: ____________________________ Section: ________________________
Teacher: __________________________________________________________________
Parent: Father: ____________________________________________________________
Mother:___________________________________________________________
Height: _____________________________ Weight: __________________
Favorite Food: _____________________________ Hair Color: __________________
Hobbies: _________________________________________________________________
Talent: _________________________________________________________________
Ambition: _________________________________________________________________
Signature: ______________________________________
EVANGELINA H. GARCIA
Adviser
Region III
District of Cabiao
CASE STUDY
S.Y. 2018-2019
Case : _____________________________________________________________________________
Grade : _____________________________________ Teacher: _______________________________
Date : _____________________________________ Problem: _______________________________
Counselor: ___________________________________
I. History of the case in brief:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
II. Data:
A. Percentage
Father: __________________________________ Place of Birth: ___________________________
Date of Birth: _____________________________ Educational Attainment: __________________
Dialect: _________________________________ Occupation: ____________________________
Religion: ________________________________
Mother:_________________________________ Place of Birth: ___________________________
Date of Birth: ____________________________ Educational Attainment: __________________
Dialect: _________________________________ Occupation: ____________________________
Religion
Children and Background:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
B. Description of Family Background in brief, including social, economics, moral, religious aspects,
etc.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
C. Finding from other tools and instruments including:

1. Formal and Informal Observation 6. Sociometric Test
2. Interview 7. Form I
3. Anecdotal Records 8. Form 137-B
4. Checklist 9. Test Records
5. Questionnaire 10.Health Records, etc.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Diagnosis:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Region III
District of Cabiao
HOME VISITATION FORM
I. IDENTIFICATION
1. Name of Pupil ____________________________________________________________

2. Name of Institution: _______________________________________________________
3. Grade/Form: _____________________________________________________________
4. Date of Birth: ____________________________________________________________
II. PURPOSE OF VISIST
__________ Regular __________ Special

__________ Absenteeism __________ Under-Achievement
__________ Discipline __________ Financial
Other: ____________________________________________________________________
Comments: ________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
III. CONTACT PERSON

__________ Mother __________ Grandmother
__________ Father __________ Grandfather
__________ Older siblings __________ Younger siblings
IV. DATE OF VISIT VISIST NUMBER
Date: ______________________ ___1___2___3___4___5___6___7___8___9___10

Time: ______________________
V. COMMENTS:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Teacher: ____________________________ __________________________________

Signature Over Printed Name Parent/Guardian
Region III
District of Cabiao
HOME VISITATION
Name of Pupil Address Purpose of Visit Date Parent’s

Signature
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Prepared by:
EVANGELINA H. GARCIA
Adviser
Noted:
LOIDA P. CRUZ
School Principal I

Anecdotal Record: Concepcion Elementaty School

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Republic of the Philippines

Name: ______________ Nickname:

I. History of the case in brief:

C. Finding from other tools and instruments including:

HOME VISITATION FORM

1. Name of Pupil ____________________________________________________________

II. PURPOSE OF VISIST

Regular Special

III. CONTACT PERSON

IV. DATE OF VISIT VISIST NUMBER

Date: ____________________ _1_2_3_4_5_6_7_8_9___10

Teacher: ______

Name of Pupil Address Purpose of Visit Date Parent’s

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