ZAPOTE ELEMENTARY SCHOOL

BRGY.ZAPOTE BIŇAN CITY LAGUNA

HOME VISITATION FORM

Name of Pupil: _______________________________________ Grade & Section:_______________
Class Adviser: _______________________________________ Date: ________________________
Purpose of Home Visitation:
I. School Problems (please check)

 Irregular attendance
 Prolonged absences
 Lack of interest in school work
 Illness
 Poor personal habits
 Lack of school materials
 Physical handicap
 Behavioral problems
 Please specify

Others __________________________________________

II.Narrative Report/ Observation

INSTRUCTIONS: Please write a narrative report in connection with the Teacher’s Home
Visitation. Please include the date, time and place the visitation was conducted and give the
names of the people parents/relatives) whom you consulted and discussed the
problems/concerns with. Then give your recommendation. Use another sheet if needed.

Recommendation:

Prepared by:__________________________
Class Adviser

Attested by:__________________________
Parents Name/ Signature