STUDENT FAMILY BACKGROUND QUESTIONNAIRE

1. Student’s Name: _______________________________________________ Age:_______

Sex:______________

Address: ___________________________________________________________________________________________
Number Street Municipality/City Province
Nationality: ___________________________________ Religion: ______________________________________
Ethnic Affiliation: ____________________________________________________________________________________
Date of Birth: _________________________________ Place of Birth:__________________________________
Birth Registered?

Yes No

2. Has student ever dropped out of school?

Yes No

If yes, for how long ___________________________________________________________________________

What reason (s) ______________________________________________________________________________

3. Distance from home to school? ____________________________________________________________km.

Means of transportation to school

Car Jeepney Pedicab Motorized Side Car

Others: _______________________________________

4. Has any member of the family dropped out of school?

Yes No

5. Is the student receiving any type of financial assistance to attend school? (Example: 4P’s recipient, Compassion,
etc.)

Yes No

If Yes, from what source/s (specify) ______________________________________________________________

6. With whom does the student live?

Both Parents Mother Father Others (specify)

7. Who helps the student in doing homework or school activities?

None Both Parents Mother Father Others: _________

8.

Information Father Mother

Living Deceased Living Deceased

Name
Age
Nationality
Ethnic Affiliation
Religion
Language (s) Dialect (s) Spoken

9. Parental Marital Status

Married Live-in Widow (er) Annulled Separated Others _______
 10. List all the members of the household including those who have migrated. Specify/check the information needed.

Name of Sex Age Relationship Migrated Education Occupation

Household M F (How Enrolled/ Highest Full Part
Members long) Completed Grade/Year Time Time
ECE

Early Childhood Education (Services such as Day Care and Preschool)

11. Is the family member of any community development organization?

Yes No

If yes, please specify __________________________________________________________________________

12. Monthly household income ____________________________________________________________________

Below P1,000 P1,000-P2,500 P2,501-P3000

P5001-P8000 P8001-P15000 Over P15,000

13. Information about Family Dwelling

A. The family

Own House and Lot Rent House Others, specify______________

B. Type of House

Concrete Semi-concrete Others, specify______________

C. Type of Toilet

Flush Pit Water-sealed No Toilet Others

specify_______

D. Source of Water Supply

Facet/Tap Water Deep Well Others, specify ___________________

E. Power Source

Electricity Kerosene Lamp Others, specify ___________________

14. Which of the following are available at home?

TV Radio Newspaper Magazine Others, specify________

Accomplished by: _____________________________________________ Date: _____________________