Republic of the Philippines

Form 137-A DEPARTMENT OF EDUCATION

Region IV-A CALABARZON
Division of Santa Rosa City LRN NO:
I. ELEMENTARY SCHOOL PERMANENT RECORD
Name: Birthday:
Parent/Guardian: Birthplace:
Address of Guardian: Guardian's Occupation:
Date of Entrance Sex:
II. REPORT ON LEARNING PROGRESS AND ACHIEVEMENT
Kindergarten: 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr
Domain RS SS I RS SS I RS SS I RS SS I
Gross Motor
Fine Motor
Self-Help
Receptive Language
Expressive Language
Cognitive
Sum Scaled Score
Standard Score
General Assessment:_____________________
II. Legend: SSdd- Suggest significant delay in over all devt. Ssdd- Suggest slight developed in over all dvt, AD- Average Dvt, SSAD- Suggest slightly Advance Dvt, SHAD- Suggest highly advance dvt.

Grade I- School: Grade II- School:

School Year: School Year:
LEARNING AREAS Q1 Q2 Q3 Q4 FG REMARKS LEARNING AREAS Q1 Q2 Q3 Q4 FG REMARKS
Mother Tongue Mother Tongue
Filipino Filipino
English English
Mathematics Mathematics
Araling Panlipunan Araling Panlipunan
Edukasyon sa
Edukasyon sa Pagpapakatao
Pagpapakatao
MAPEH MAPEH
Music Music
Arts Arts
PE PE
Health Health

General Average: General Average:

Class Adviser: Class Adviser:
Eligible for Admission to Grade Eligible for Admission to Grade
Grade III- School: Grade IV- School:
School Year: School Year:
LEARNING AREAS Q1 Q2 Q3 Q4 FG REMARKS LEARNING AREAS Q1 Q2 Q3 Q4 FG REMARKS
Mother Tongue Filipino
Filipino English
English Mathematics
Mathematics Science
Science Araling Panlipunan
Araling Panlipunan Edukasyon sa
Pagpapakatao
Edukasyon sa Pagpapakatao Edukasyong Pantahanan at
Pangkabuhayan

MAPEH MAPEH
Music Music
Arts Arts
PE PE
Health Health

General Average: General Average:

Class Adviser: Class Adviser:
Eligible for Admission to Grade Eligible for Admission to Grade
Grade V- School: Grade VI- School:
School Year: School Year:
LEARNING AREAS Q1 Q2 Q3 Q4 FG REMARKS LEARNING AREAS Q1 Q2 Q3 Q4 FG REMARKS
Filipino Filipino
English English
Mathematics Mathematics
Science Science
Araling Panlipunan Araling Panlipunan
Edukasyon sa
Edukasyon sa Pagpapakatao
Pagpapakatao
Edukasyong Pantahanan at Edukasyong Pantahanan at
Pangkabuhayan (EPP) Pangkabuhayan (EPP)

MAPEH MAPEH
Music Music
Arts Arts
PE PE
Health Health

General Average: General Average:

Class Adviser: Class Adviser:
Eligible for Admission to Grade Eligible for Admission to Grade
DESCRIPTION GRADING SCALE REMARKS DESCRIPTION GRADING SCALE REMARKS

Outstanding 90-100 Passed Fairly Satisfactory 75-79 Passed

Very Satisfactory 85-89 Passed Did not meet Expectations Below 75 Failed
Satisfactory 80-84 Passed
 REPORT ON LEARNER'S OBSERVED VALUES
III.
Grade 1 SY ________ Grade 2 SY ________ Grade 3 SY ________
Core Values Behavior Statements
1 2 3 4 1 2 3 4 1 2 3 4
Expresses one's spiritual beliefs while
respecting spiritual beliefs of others.
Maka-Diyos
Shows adherence to ethical principles
by upholding truth.
Is sensitive to individual, social, and
cultural differences.
Makatao
Demonstrates contributions toward
solidarity.
Cares for the environment and utilizes
Makakalikasan resources wisely, judiciously,
and economically.
Demonstrates pride of being Filipino;
exercises the right and responsibilities
Makabansa of Filipino citizen.
Demonstrates appropriate behavior in
carrying out activities in the school,
community and country.

Grade 4 SY ________ Grade 5 SY ________ Grade 6 SY ________

Core Values Behavior Statements
1 2 3 4 1 2 3 4 1 2 3 4
Expresses one's spiritual beliefs while
respecting spiritual beliefs of others.
Maka-Diyos
Shows adherence to ethical principles
by upholding truth.
Is sensitive to individual, social, and
cultural differences.
Makatao
Demonstrates contributions toward
solidarity.
Cares for the environment and utilizes
Makakalikasan resources wisely, judiciously,
and economically.
Demonstrates pride of being Filipino;
exercises the right and responsibilities
Makabansa of Filipino citizen.
Demonstrates appropriate behavior in
carrying out activities in the school,
community and country.
AO- Always Observed SO- Sometimes Observed RO- Rarely Observed NO- Not Observed

IV. REPORT ON ATTENDANCE

No. of No. of No. of days
Grade Level No. of days absent Cause/s Cause/s
school days tardy
Kindergarden

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

CERTIFICATION
________________________________________

________________________________________

________________________________________

This is to certify that this is a true record

of__________________________________________________. This student is eligible for admission
to_________________ . He/She has no property/responsibility in this school. Issued this__________ of
_______________________________
Not valid without seal
201____.

__________________________________________ ___________________________________________
Date Teacher Counselor

__________________________________________ ___________________________________________
Date School Head