SURVEY FORM

I.

Personal Data
a. Name of child b. School c. Home Address d. Grade/Yr. & Section e. Age f. Date of Birth -

II.

Family Background
Mother

Father

a. Name
b. Education Attainment
c. Occupation
d. Socio-eco level of the family:

Good _______ Fair _______ Poor

_______
e. Language spoken at home
f. Church affiliation
g. Marital status of parents:

Living together _______

___

Separated _________
One parent living: Father _______

___

Mother

____________
h. Living with stepmother _______ Stepfather ___________ Others:
Specify: _________
i. Pupil/student lives in other home/s (describe)

j. Number in the family: __________

Number of Siblings

______________
k. Order of birth
l. State one problem you encounter on school and home