MS ELEMENTARY

PUPILS BACKGROUND
Pupils Name: __________________________________________________ Nickname:
___________________

Occupation: __________________________ Language Spoken:

______________________________________

GRADE ONES.Y.:__________

Parental Status: ___Married ____Living-In ____Separated

_____Widow/Widower _______Others (pls. specify)

Grading

Address: __________________________________________________________________________________

No. of Family Member Drop-Out: _________________

Member of Com. Devt. Org. _______Yes _________No

Age: _____________________ Gender: _______________ Nationality:

________________________________

Monthly Household Income: ___5,000- 10,000 ____

11,000-15,000 ___ 16,000-20,000 ___Others (pls. specify)

Ethnic Affiliation: _______________________________ Religion:

____________________________________

Appliances at home:

Students live with: _____________Parents ___________Relatives ____________________Others

(pls. specify)
Person who helps child in Homework: _____Parents_____ Relatives __________________Others
(pls. specify)

FAMILY BACKGROUND
Fathers Name: _________________________ Nationality: ___________________ Age:
__________________
Occupation: __________________________ Language Spoken:
______________________________________
Mothers Name: _________________________ Nationality: ___________________ Age:
_________________

3r

4t

FINA
L

4t

FINA
L

Average

Grading

Drop-Out History: ____Yes ___ No How long? ________ Reason/s:

__________________________________

Source of Financial Assistance: ______Parents _______Guardian _____DSWD __________Others

(pls. specify)

2n

GRADE THREE
S.Y.:__________

Date of Birth: ________________ Place of Birth: _______________________ Birth Registered:

___Yes ____ No

Distance of School from home: _______________ Means of Trans. to school:

___________________________

1st

1st

2n

3r

Average

EDUCATIONAL PROFILE
_________________________________________________________________________
House: _____own _______rented ______ _living with parents/relatives _______________Others
(pls. specify)
Type of House: ___Single Unit ______Duplex ______Apartment ________Townhouse
________Condominium
Type of Toilet: ________flush toilet ________ Squat toilet _________ Urinals _________Outhouse
or Pit Toilet
Source of Water Supply: _____ Nawasa/Maynilad ______Deep well ____Water Pumps
___Others (pls. specify)
Source of Power Supply: ____________Meralco __________________________________Others (pls.
specify)

ABSENTEEISM AND DROP- OUT PROFILE

Grade
Level

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

No. of Days
Absent

Reasons
Summer
Drop-out?
How long?
Reasons

HEALTH AND NUTRITION PROFILE

Grade Level

Grad
e1

Grad
e2

School Year
Nutritional Status- Weight (kg)
Remarks Height (cm)
Immunization
BCG
DPT
Polio
Hepa
Whooping Cough
Chicken Fox
Measles

GRADE TWO
S.Y.:__________

Illness Incurred during the year

Major Accidents

Grading

1st

2n

3r

4t

2n

3r

4t

FINAL

Average

GRADE FOUR
S.Y.:__________
Grading
Average

1st

FINAL

Grad
e3

Grade
4

Grade
5

Grade
6