E N G L I S H: Parents' Name Date of Birth Place of Birth Educationa L Attainmen T Religio N Occupatio N Fathe R Moth Er

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Name :

Nickname :
(Last Name)

(First Name)

(Middle Name)

Date of Birth:

Place of Birth:

Address:

Learner Reference Number:

Date of
Birth

Parents Name

Educationa
l
Attainmen
t

Place of
Birth

Religio
n

Occupatio
n

Fathe
r
Moth
er
Brothers/Sisters according to the position in the family. (Exclude married members).
1. _________________________ 3.___________________________ 5. ____________________________

Indicate any
Physical disability
___________________
Height
Weight
Nutritional
Health
Legend:
Nutritional Level
O
Obese
O
Over Weight
N
Normal
W
Wasted
SW Severely

Health Condition
E
VS
G
F
P

Excellent
Very
Good
Fair
Poor

VISUAL ACTIVITY TEST


RIGH
RESU
LEFT

RESU

E
N
G
L
I
S
H

Types of
Miscues

Types of
Miscues

Major
Miscue

Post-Test ______________

Self
Correcte
d

Miscue

# of
Miscue

Major
Self
Miscue Corrected

Frustration
Instructional
Independent
NonPre-Test _______________
Miscue

# of
Miscue

Major
Miscue

Frustration
Instructional
Independent
NonPost-Test ______________

Self
Correcte
d

Miscue

# of
Miscue

Major
Self
Miscue Corrected

Mispronunciation
Substitution
Insertion
Omission
Reversal
Repetition
Refusal to
Pronounce
Total
Reading Level

AUDITORY TEST
RIGHT
LEFT

Miscue

# of
Miscue

Mispronunciation
Substitution
Insertion
Omission
Reversal
Repetition
Refusal to
Pronounce
Total
Reading Level

F
I
L
I
P
I
N
O

Pre-Test _______________

Frustration
Instructional

Frustration
Instructional

RESULT

ENGLISH
DENTAL RECORD
TEETH
NORMA
W/
L
DEFECT
S

Pre-Test
REMARK
S

Spe
ed

Readi
ng
Time

Comprehensi
on Level

FILIPINO

Post-Test
Spee
d
Level

Spee
d

Readi
ng
Time

Pre-Test
Spee
d
Level

Comprehensio
n Level

Spe
ed

Readi
ng
Time

Comprehensi
on Level

Post-Test
Spee
d
Level

Spee
d

Readi
ng
Time

Comprehensio
n Level

(Guidance Form 3)
DATE

GRADE &
SECTION

PLACE

OBSERVER

INCIDENT/REPORT

Spee
d
Level

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