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Republic of the Philippines

Region III- Central Luzon


Department of Education
Schools Division of Tarlac Province
PITOMBAYOG HIGH SCHOOL
Mayantoc, Tarlac

HOME VISITATION FORM


Name of Learner:_______________________________ Section:____________
Address:_______________________________________ Date:______________
With Previous Case:_____YES_____NO. if Yes specify_________ No. of Absent:____
No. of Home Visitation Made:_____ No. of Consultation Made between Learner/Parent and Teacher:_______
1. Purpose of Home Visit?
______________________________________________________________________________
__________________________________________________________________

2. Who were present?


______________________________________________________________________________
__________________________________________________________________

3. Are the family’s basic needs being met? Describe what family they have.
______________________________________________________________________________
__________________________________________________________________

4. What issues were discussed during home visit?


______________________________________________________________________________
__________________________________________________________________

5. Were any recommendations/suggestions given to parent/Family?


a. What are they?
____________________________________________________________________
__________________________________________________________

b. Who is responsible for follow up?


____________________________________________________________________
__________________________________________________________

6. Next Steps?
Action Target Date Responsible Person
_________________ _________________ ___________________
_________________ _________________ ___________________
_________________ _________________ ___________________

________________________________ ____________________________________
Signature over printed name of Learner Signature over printed name of Parent/Guardian
Contact Number:______________________ Contact Number:__________________________

__________________________________________
Signature over printed Name of Teacher

__________________________________________
Guidance Counsellor
Republic of the Philippines
Region III- Central Luzon
Department of Education
Schools Division of Tarlac Province
PITOMBAYOG HIGH SCHOOL
Mayantoc, Tarlac

DROPPING FORM
Name of Learner:_______________________________ Section:____________
Address:_______________________________________ Date:______________
With Previous Case:_____YES_____NO. if Yes specify_________ No. of Absent:____
No. of Home Visitation Made:_____ No. of Consultation Made between Learner/Parent and Teacher:_______

Reason/s of Dropping: _______________________________________________


______________________________________________________________________
______________________________________________________________________

Interventions Made: __________________________________________________


______________________________________________________________________
______________________________________________________________________

Agreement: __________________________________________________________
______________________________________________________________________
______________________________________________________________________

Recommendation/s: _________________________________________________
______________________________________________________________________
______________________________________________________________________

________________________________ ____________________________________
Signature over printed name of Learner Signature over printed name of Parent/Guardian
Contact Number:______________________ Contact Number:__________________________

__________________________________
Adviser

LEORINA G. OBISPO
Guidance Counsellor

MARCELO T. ESTEBAN, Ed.D.


Principal II

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