Republic of the Philippines

Department of Education
Region V (Bicol)
DIVISION OF CITY SCHOOLS
City of Iriga South District
SANTIAGO INTEGRATED SCHOOL
Iriga City

HOME VISITATION FORM

GRADE I-3 COURTEOUS
Date___________________

Name of Pupil_______________________________
Home Address_______________________________
Birth Order_________________________________
Type of Home_______________________________

___Owned ____Wood ____Rented

___Concrete/Wood ____Concrete
INFORMATION
Age Educational Occupation Annual
Attainment Income
Father:
Mother:
Siblings

Activities done before school:_____________________________________________________________

Activities done after school:______________________________________________________________
Transportation:_____________________How many rides?________Cost of transportation/day_______
Is there electricity at home?______Yes______None
Is there a definite time for sleep?____________What time?___________Wake up time?_____________
Are there materials available to help the pupil’s assignment?______________
Schedule of watching T.V________(Yes)________(None)
Are week activities allowed?_______(Yes)________(No)
__________playing __________attending mass
__________studying __________other

Reasons for conducting home visitation:_________________________________________________

___________________________________________________________________________________
___________________________________________________________________________________

Remarks:

______________________________
Parent’s Signature AMY S. BARACINA
Teacher-Adviser