Anecdotal-home-visitation-form.docx

Republic of the Philippines Department of Education Region V Division of City Schools Bacon East District BACON EAST CENTRAL SCHOOL Sorsogon City

HOME VISIT FORM Name of Pupil: _______________________________________ _____ Date of Birth: _______________________________________ DATE OF VISIT: Date: ____________________________ Time:____________________________ PURPOSE OF VISIT: Regular Absenteeism Discipline Special

Grade & Section _________________ Visit Number _______________

Under-Achievement Financial Others

Comments: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ PERSON CONTACTED: Father Mother Grandmother

Grandfather Older Sibling Younger Sibling

Comments: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ __________________________________________________ Name & Signature of Person Contacted Noted: __________________________________ Name of Adviser

Republic of the Philippines Department of Education Region V Division of City Schools Bacon East District BACON EAST CENTRAL SCHOOL Sorsogon City

ANECDOTAL RECORD FORM

Name of Pupil: ___________________________________________ Date of Birth: _______________________________________

Grade & Section _________________

Date of Incident:________________________ Time of Incident:________________________ Narrative of Incident: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Action Taken: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________

______________________________________________ Name of Adviser

Republic of the Philippines Department of Education Region V Division of City Schools Bacon East District BACON EAST CENTRAL SCHOOL Sorsogon City

INCIDENT REPORT Pupil’s Name: _________________________________________________ Date:_______________ Teacher:_____________________________ ___ ___ ___ ___ ___ ___ ___

Refusing to work Throwing items Disrupting with noises Teasing or bullying classmates Moving out of assigned area Sleeping Employing excessive and inappropriate attention-seeking behaviors

___ ___ ___ ___ ___ ___ ___ ___

Destroying property Talking without permission Using inappropriate language Refusing to follow directions Making inappropriate gestures Using physical aggression Improper use of technology Others ________________________________

Supporting Details ___________________________________________________________________

Actions Taken ______________________________________________________________________

___________________________ Pupil’s Signature

___________________________ Parent’s Signature

Republic of the Philippines Department of Education Region V Division of City Schools Bacon East District BACON EAST CENTRAL SCHOOL Sorsogon City

Teacher – Learner Dialogue Date: ____________________________ Name of Pupil: ___________________________________________ Grade & Section:

_____________________

Situation: ○ Bad Attitude o Making noises o Not participating o Yelling out in class o Attendance/tardiness o Unkind/rude to others o Choosing not to work o Disrespectful/uncooperative o Bossy/trying to be the teacher ○ Sickness ○ No assignment ○ Discipline ○ Family Problems ○ Lack of Interest ○ Parents Others: ______________________________ ○ attitude towards schooling Agreement: ○

○ ○ ○ ○ ○ ○ ○ ○ ○

Always try to do my best work. Be kind and helpful to my classmates. Show respect for myself, my school, and other people. Obey classroom, school rules. Show respect for property by not stealing or vandalizing. Come to school prepared with my homework and my supplies. Believe that I can and will learn. Spend at least 15 minutes each day studying or reading at home. Talk with my parents each day about my school activities. Others: ______________________________________

Signature of Pupil: ________________________________________ Teacher’s Signature: _______________________________________

Republic of the Philippines Department of Education Region V Division of City Schools Bacon East District BACON EAST CENTRAL SCHOOL Sorsogon City

__________________

MR. NELEUTERIO E. DELLOSA Elementary School Principal II Bacon East Central School

Sir: I would like to ask permission from your good office to conduct a home visit for my pupil, ________________________________________________________ in ______________________, Bacon District, Sorsogon City on ___________________.

Very truly yours, EVA D. DIALOGO Teacher Noted: NELEUTERIO E. DELLOSA Principal II