Name of Learner: _________________________________________________ Age: ___________

Grade Level:____________ Birthday: __________________ Gender: _______________

Name of mother: _____________________________ Mother’s Education Level: ____________________
Name of father: _____________________________ Father’s Education Level: ______________________
Number of siblings in the family: ________________________

Instructions: For one week, record the pupil's observations in the appropriate column. This is one technique for the
teacher to gain a better understanding of the learner.
Monday Tuesday Wednesday Thursday Friday
1. Who is with the child
at home?
- Parents
- Grandfather and
grandmother
- Aunts and aunts
- If others: Please
specify
2. What time did the
child sleep last night?

3. Did the child eat

before it went to
sleep?

4. What time did the

child wake up this
morning?

5. Did the child eat

breakfast before
going to school?
If Yes…
- What did the child
have for breakfast?
If No…
- Why didn't the child
have breakfast?
6. Who takes care of the
child going to school?

7. Does the child look

good every time he or
she goes to school?
 If No..
- What is the
possible reason?
8. Did the child attend
school on time?
If No..
- What is the
possible reason?
9. Does the child do the
homework if there is
any?
If No..
- What is the
possible reason?
10. Does the child
participate in class
discussion?
If No..
What is the possible
reason?
11. Does the child have
enough school
materials such as
paper, pencil, ball pen
and so on?
If No..
- What is the
possible reason?
12. Does the child
complete the
activities given by the
teacher that day?
If No..
What is the possible
reason?
13. Does the child have
enough food for
recess time?
If Yes….
- Please write down
the child's food during
recess.
 If No...
- What is the
possible reason?
14. Is the child being
picked up on time to
go home?
15. Who often picks up
the child at home?
- Parent
- If others: Please
specify

Teacher comment on pupil observation:

_______________________________________________________________________________________________
_______________________________________________________________________________________________

_______________________________________________________________________________________________
_______________________________________________________________________________________________

Prepared by:
______________________________
Name of Adviser

Checked by:
______________________________
Name of Principal