Republic of the Philippines

DEPARTMENT OF EDUCATION
Caraga Region
Division of Surigao del Sur
Cagwait District
UNIDAD NATIONAL HIGH SCHOOL
School ID: 304924

ANECDOTAL RECORD

Name: ________________________________________Date of Birth : ______________ Age: ______

Year and Section: ____________________________ Gender: Male ( ) Female ( )
Father’s Name: ______________________________________Occupation: ____________________
Address: ______________________________________________________________________________
Mother’s Name: _____________________________________ Occupation: _____________________
Address: ______________________________________________________________________________
(If not living with Parents)
Name of Guardian: __________________________________ Occupation: ____________________
Address: _____________________________________________________________________________
Present Address: _____________________________________________________________________

Date Time Report/Observation

Prepared by:

CHARLOTTE JUNETH PEARL P. LUMANAO

Class Adviser

Note: If you have observed irregularities on student’s behavior, conduct

the behavior checklist interview. Attach the said form.

Address: Unidad, Cagwait, Surigao del Sur

Email Address: 304924@deped.gov.ph
Contact number: 214-6076
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Caraga Region
Division of Surigao del Sur
Cagwait District
UNIDAD NATIONAL HIGH SCHOOL
School ID: 304924

ANECDOTAL RECORD FORM

Observer/Teacher’s Name: _______________________________ Observation Date: _________

Year/Grade Level Assignment: ____________________________ Observation Time: _________

Student’s Name: ______________________________________Grade & Section: _______________

Father’s Name: _______________________________________ Occupation: ___________________
Mother’s Name: _______________________________________ Occupation: ___________________
Guardian’s Name: (If not living w/ Parents) ____________________
Occupation: _____________
Description of the incident (What happened)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Description of the location/Setting: (Where & how did it happen?)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Notes/Recommendation/Actions:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Date Referred to the Guidance Counselor: ___________________________________________

------------------------------------------------------------------------------------------------------------

Teacher’s Intervention: _____________________________________ Date: ____________________

Teacher’s Evaluation: _________________________________________________________________
Student’s Action Plan: ________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Students/Parents Name and Signature Counselor’s Name and Signature

Address: Unidad, Cagwait, Surigao del Sur

Email Address: 304924@deped.gov.ph
Contact number: 214-6076
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Caraga Region
Division of Surigao del Sur
Cagwait District
UNIDAD NATIONAL HIGH SCHOOL
School ID: 304924

1st FOLLOW UP

Teacher’s Evaluation: _________________________________________________________________

______________________________________________________________________________________

Student’s/Parent Action Plan: _________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Students/Parents Name and Signature Counselor’s Name and Signature

2nd FOLLOW UP

Teacher’s Evaluation: _________________________________________________________________

______________________________________________________________________________________

Student’s/Parent Action Plan: _________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Students/Parents Name and Signature Counselor’s Name and Signature

3rd FOLLOW UP

Teacher’s Evaluation: _________________________________________________________________

______________________________________________________________________________________

Student’s/Parent Action Plan: _________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

Students/Parents Name and Signature Counselor’s Name and Signature

Address: Unidad, Cagwait, Surigao del Sur

Email Address: 304924@deped.gov.ph
Contact number: 214-6076