Republic of the Philippines

Department of Education
Region III
Division of Bulacan
FELIZARDO C. LIPANA NATIONAL HIGH SCHOOL

GUIDANCE CENTER

SARDO
STUDENT AT RISK OF DROPPING OUT

NAME: _______________________________________________ AGE: ___________

YEAR AND SECTION: ____________________________________________________

ADDRESS: _____________________________________________________________

DROP-OUT HISTORY
HOW
SCHOOL
LEVEL MANY REASON/S
TIMES YEAR

1[ ]
2[ ]
ELEM.
3[ ]
4[ ]
1[ ]
2[ ]
1ST YR.
3[ ]
4[ ]
1[ ]
2ND YR.
2[ ]
3[ ]
4[ ]
1[ ]
2[ ]
3RD YR.
3[ ]
4[ ]
1[ ]
2[ ]
4TH YR.
3[ ]
4[ ]

I CONSIDER HIM/HER AS SARDO BECAUSE OF

□ CUTTING CLASSES / HALF DAY

□ ABSENTEEISM

□ BEHAVIOR PROBLEM, SUCH AS: __________________________________

□ OTHERS, SPECIFY: ______________________________________________

ACCOMPLISHED BY: __________________________________ DATE: ___________

NAME AND SIGNATURE

-------------------------------------------------------
THIS SPACE IS FOR GUIDANCE COUNCELOR

___ FAMILY ___ INDIVIDUAL ___ COMMUNITY ___ SCHOOL

SITUATION:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________

ACTION/S TO TAKE:
______________________________________________________________________________

ACTION/S TAKEN:
______________________________________________________________________________

RESULT/S:
_____________________________________________________________________________________________
_______________________________________________________________