`12356789-MINDANAO UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cagayan de Oro City

GUIDANCE SERVICES UNIT
Manual
I. General Introduction
A. Highlights and Rationale
Guidance is defined as the process of helping individuals understand
themselves and their world. It is essential because of human needs
and desires. Around us are conditions and situations which reflect
wasted human energy, misspent lives, misery, poverty, disaster,
unnecessary loss of lives, and all because of lack of direction and
wrong choices of vocation, recreation, companions, educational
opportunities and sense of values. We cannot be completely satisfied
with the things we have or possess. Even those who claim that they do
not need any help find that they need someone to talk to in order to
have an outlet for their pent-up emotions and feelings. (Shertzer and
Stone)
The tendency to guide is instinctive in most of us. Within us is a desire
to help others sometimes latent, sometimes active, but the desire is
there. (Shertzer and Stone)
Guidance is an integral part of the universitys education program. It
aims to maximize the use of its materials and human resources in the
total development of the students in assisting them adjust to school
life, overcome various problems related to school work, day to day life
and the development of their habits, attitudes, skills and knowledge to
prepare them for successful employment or entrepreneurship.
B. Objectives of the Manual
The manual will serve as a guide in availing the services of
the unit. This will also help students, teachers and administrators
become aware of the services the unit offers, the procedures on how to
avail and the implementation of its programs and activities.
II. Flow and Procedure
Guidance Services is available to all bonafide students of the
university including alumni, returnees and those who wish to transfer
to the university, parents, visitors, teachers and colleagues. The
services can be availed simply by visiting the office or by appointment.
It is on a first come first serve basis. The client/s will be attended to by
the Officer of the Day/Student Assistant and will sign the log-book and
directed to the assigned counselor or to any available counselor.

III

The VMGO of the Unit

VISION
Provide a client-friendly environment and services that will promote
behavioral competencies.
MISSION
To fully direct its efforts and commitment in guiding students
become highly motivated, value-laden, responsible, resilient to lifes
challenges and cultivate in them a sense of pride and maturity.
GOAL
To develop psychologically sound individuals by providing resources
and effective guidance services.
OBJECTIVE
To maximize the use of its resources in the development of
students well-being.

1V. The General Guidance Services Program

A. Individual Planning
1. Individual Inventory Service
Description
- is the collection,
students data.

organization and utilization of

Flow of Implementation
Freshmen students and transferees are required to fillout the Questionnaire for Initial Interview which also
serve as the Personal Data Sheet
Download List of Officially Enrolled students from the
system
The Applications for Admission together with the
Answer Sheets of the freshmen students and
transferees from the Admissions Office and the
Personal Data Sheets are filed by program
Records of old students are also filed by program and
year level
Interview and counseling notes are reflected in the
students individual Personal Data Sheet
Records of student- leavers are pulled out and filed as
inactive
Records of graduates are also pulled-out and filed by
program and college

2. Career Center Services

Description
-aims to help students know themselves (values,
interests, skills, strengths and weaknesses), explore career
options thru the use of Occupational Brochures, Career Guide
and Psychological Test Results in career decision-making and
assist graduating students in their job application (resume
and application letter writing/critiquing )

Flow of Implementation
Extend career guidance to students who visit the
office or referred by the Career Peer Assistant
Coordinate/collaborate with Career Center Director in
the conduct of activities like OJT Orientation, Preemployment and Job Expo
Perform tasks as assigned by the Career Center
Director
3. Follow-up Service
Description
- an integral part which monitors students progress
with regards to their academic performance, home and
other concerns
Flow of Implementation
Students
previously
counseled
with
serious
problems/concerns are followed-up or advised to come
back for another counseling session
Students referred by Student Affairs Welfare Office for
counseling for certain violations as provided in the
Student Handbook are also followed-up
Students who failed to fill-out the Personal Data Sheets
are also required to visit the Guidance Office and
followed-up
B. Responsive Services
1. Orientation Program
Description

-an activity conducted at the start of every semester

where all freshmen students and transferees are
gathered. The different student services like Medical,
Dental, Guidance, Scholarships, Sports, Cafeteria,
Academic and Non-academic policies are discussed.
Flow of Implementation
Coordinate/collaborate with Student Affairs Welfare
Office
Perform tasks as assigned by the Head, SAWO
Discuss Guidance Services and other related topics

2. Interview and Counseling

Description
-a process by which a troubled person/client is
helped to feel and behave in a more personally
satisfying manner through interaction with a counselor
(Shetzer and Stone)
Flow of Implementation
Announce/invite freshmen students during the
orientation program to visit the guidance office and
see their assigned guidance counselor for initial
interview
issue call slip and check students class schedule in
the system
send call slip through the student assistant in their
classroom
attend to walk-in/invited student
coordinate with subject teachers/chairmen to allow
students to visit the guidance office for interview and
counseling
counsel students referred by instructors and SAWO
conduct exit interview to graduating students

3. Information Service
Description
- designed to provide students with
educational,
personal-social
and
career
information needed to understand themselves and
their environment
Flow of Implementation

 Plan for the date, venue and topics for discussion

and the resource person/s to be invited
Prepare communication reflecting budget needed
and attached tentative program for approval
Reserve venue by filling-out the reservation form
provided by the AVR staff
Once
communication/request
is
approved
disseminate information to the offices concerned
(Deans and Chairmen); provide a copy of the
approved communication, program and schedule
Prepare communication for the resource speaker/s
Coordinate with other persons involved in the
program and other units for other needs
Post schedule in strategic places
Registration by program/course
Conduct Students Evaluation of the Activity at the
end of the program and consolidate the results
Prepare summary of students attendance

V. Systems Support
A. Guidance Staff Professional Development
Description
- The guidance staff is encourage to attend
seminars/workshops/trainings
annually
to
enhance knowledge and skills in the field of
Guidance and Counseling.
Flow of implementation
Inform staff of the invitation to attend
seminars/workshops/ trainings
Interested staff will fill-out the Request to Attend
form and process for approval
B. Committee Participation
Description
- the Guidance Staff is assigned to the
different committees by the administration as
needed. At present, the staff is a member of the
Fact Finding Dialogue of SAWO and Ecumenical
Thanksgiving and Baccalaureate Celebration
Flow of implementation
1. Fact Finding Dialogue

1.1 A memorandum is received for the schedule

and other
related information regarding the Fact Finding
Dialogue
signed by the Director, Student Affairs Welfare
Services
1.2 Attend the dialogue
1.3 Sign SAWS report to the Vice-President for Student
Affairs with the
recommendations of the case
2. Ecumenical Thanksgiving and Baccalaureate
Celebration
H
2.1 Receive official notice from the Chairman of
the
Committee
2.2 Prepare Invitation Letter to the celebrants
( Catholic, Muslim
and Evangelical) signed by the Chairman
2.3 Prepare communication requesting for Budget
(Celebrants
honoraria and meals)
2.4 Prepare program and coordinate with
the staff at the
publication for reproduction
2.5 Send invitation letters to the celebrants
2.6 Coordinate with Sanghimig Chorale for the
Songs
2.7 Coordinate with other staff for the venue
2.8 Prepare and distribute Program to the different
offices
2.9 Post Information in strategic places
3.0 Coordinate with Faculty/Deans/Chairmen and
non-teaching
staff for students, faculty and personnel
attendance
3.1
Coordinate with the cafeteria staff for meals
VI. Job Descriptions
A. Guidance Coordinator
Specific Duties and Responsibilities:
Prepares/consolidates Annual Work and Financial Plan, Annual
Procurement Program/PPMP, Quarterly Monitoring and Evaluation of
Work and Financial Plan and other periodic reports and documents
that may be requested
Plans, coordinates and spearheads guidance activities (Information
Service) e.g. Freshmen Orientation, lecture series/symposia etc.

 Serves as Guidance Counselor for the College of Arts and Sciences,

BS Information Technology and BS Auto-Mechanical Technology
students
Assists the Director of the Career Center in providing Career
Services to the students (Career Advising, Pre-employment
Orientation, On the Job Training Orientation & Job Expo)
Gathers, files and maintains students records
Prepares/improves individual inventory forms
Extends interview and counseling to students
Visits satellite campuses and extends guidance services
Makes referral to program chair and qualified personnel of different
colleges and units to further assist students
Follows-up students previously counseled and walk-in
Orients and supervises student assistants and student immersion
Provides documents as requested for Accreditation
Attends staff meetings called by VPSA and Director of SAWS
Attends university-wide activities
Coordinates with the Deans, Chairmen, Instructors and other office
personnel

Performs Other Related Tasks

Attends to visitors queries
Committee member on students investigation/dialogue conducted by
SAWS
Committee member on Ecumenical Thanksgiving and Baccalaureate
Celebration
Prepares/withdraws office supplies and materials

B. Guidance Counselor
Specific Duties and Responsibilities:
Assists the Guidance Coordinator in preparing/consolidating Annual
Work and Financial Plan, Annual Procurement Program/PPMP,
Quarterly Monitoring and Evaluation of Work and Financial Plan and
other periodic reports and documents that may be requested
Assists the Guidance Coordinator in making plans and coordination
in the conduct of guidance activities ( Freshmen Orientation ,
lecture series/symposia, etc. )

 Assists the Director of the Career Center in providing Career

Services to the students (Career Advising, Pre-employment
Orientation, On-the-Job Training Orientation & Job Expo)
Gathers, files and maintains students records
Prepares/improves individual inventory forms
Extends interview and counseling to students
Visits satellite campuses and extends guidance services
Makes referral to program chair and qualified personnel of different
colleges and units to further assist students
Follows-up students previously counseled or walk-in
Provides documents as requested for Accreditation
Attends staff meetings called by VPSA and Director of SAWS
Attends university-wide activities
Coordinates with the Deans, Chairmen, Instructors and other office
personnel
Performs Other Related Tasks
Attends to visitors queries
Committee member on students investigation/dialogue conducted by
SAWS
Committee member on Fact-Finding
Committee member on the Cafeteria Inspection Team
Committee member on Ecumenical Thanksgiving and Baccalaureate
Celebration

VII.

Forms

A. Evaluation
1. Client Satisfaction Survey

CLIENT SATISFACTION SURVEY

The Guidance Services Unit (GSU) is carrying out a survey to
collect information on GSU clients satisfaction with the
services we provide.
In an effort to serve you better, we would appreciate it if you
would take a few minutes to answer the following questions as
honestly as possible. Your valuable responses will assist us in
providing you with best service possible.
Thank you for your help, it is greatly appreciated.
Guidance
Counselor

1. What is your purpose in visiting the Guidance office? Please

check.
____ Initial interview
____Terminal Interview
____ Referral
____ Counseling
____ Consultation
____ Follow up
2. What college do you belong?
____ CAS
____ CEA

____ CIIT

____ CPSEM

3. What is your year level?

____ 1st
____ 2nd
____ 3rd
____ 4th ____5th
4. What is your sex?
____ Male
____ Female
5. In general, how would you rate the Guidance Services?
____ Very good ____ Good ____ Acceptable ____ Noncommendable
6. How do you feel about the waiting time, after the office opens
at 8:00 AM?
(Not when you arrive before it opens)
____ Much too long
____ Too long
____ About
right
7. Do you usually receive the service/s you need during your
visit?
____ Yes
____ No
8. When you arrived, how would you rate the assistance you
received from
the receiving section?
____ Prompt and helpful
____ Helpful after I
asked
____ Slow and unhelpful
____ Rude
9. Which term best describes the person who served you?
____ Friendly
____ Caring
____
Professional

____ Uncaring

____ Insensitive

____

Rude
10. Thank you for answering our questions today. Is there any
other
information/comments/suggestions/recommendations
you
would like to provide? Use the space provided below.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

2. Students Evaluation of Activity

MINDANAO UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cagayan de Oro City
STUDENT'S EVALUATION OF ACTIVITY

Title of
Activity_____________________________________________________
Date: _______________Time: ______________ Venue:
____________________
Department: ___________ Course & Year Level: ______________
Sex:________
In an effort to serve you better, we would appreciate it if
you would take a few minutes to evaluate honestly this
activity by checking the column that corresponds to your
rating. Your valuable responses will help us improve in
conducting more activities in the future. Thank you for your
help.
Guidance
Counselor
Rating Scale
3.5 - 4.0
2.5 - 3.49
1.5 - 2.49
1.0 - 1.49

Verbal Description
Excellent
Very Satisfactory
Satisfactory
Needs Improvement

CRITERIA
1. Relevance/appropriateness of the activity
2. Organization of the activity
3. Benefit to the students
4. Extent of audience participation
5. Audio and visual presentation
6. Attainment of objectives of the activity
7. Over-all impression of the activity

Comments/Suggestions/Recommendations:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Thank you!

GUIDANCE SERVICES UNIT

ACCOMPLISHMENT REPORT
A. INDIVIDUAL INVENTORY
B. INTERVIEW AND COUNSELING
Number of student/s served by program:

Initial Interview
Course

Male

Female

Total

Male

Female

Total

Course

Male

Female

Total

Course

Male

Female

Total

Course

Male

Female

Total

Course

Male

Female

Total

Walk-in (Counseling/Consultation/other matters)

Course

Referral

Follow-up

Exit Interview

Summary:

Initial Interview

Walk-in (Counseling/Consultation/ and others)

Referral
Follow-up
Exit Interview
Total

C. INFORMATION SERVICE
Summary of Attendance:
Course

Male

Female

Total

Total

D. Other Related Tasks

5.Forms (Description)
A. Guidance Forms
a. Students Personal Data Sheet and Guide to Initial
Interview - this form is filled-out by the student during
his/her admission to the university. It contains personal
information about the student and will serve as a guide to
the counselor in getting important details with regards to
adjustment to college life. At the bottom is the
Counselors Notes where counseling and interview notes
are written or recorded by the counselor
b. Call-slip - is used by the counselor to call or invite
student/s to visit the office for interview and counseling
or for other reasons
c. Reasons for Students Failures - is used as a guide for
counselors in conducting interview and counseling to
student/s who obtained academic deficiencies or failing
grades usually during mid-term
d. Referral Slip - is used in making a referral after extending
interview and counseling to a student/s and found to
have other needs that can be helped or facilitated by
other professionals or qualified personnel like Physician,
Chairman of the program, Dentist etc
e. Logbook of Guidance Counselor - a record of the daily or
weekly activities, reminders and upcoming activities.

f.

Evaluation of the Activity - is filled-out by the students to

evaluate the activities held or conducted. The information
provided will help improve the succeeding activities or
programs.

g. Individual Performance Commitment and Review (IPCR) - a

report prepared by the individual staff annually to assess
or evaluate his/her performance .
h. Office Performance Commitment and Review - is a
consolidated report of output or performance of the staff,
prepared by the Head of the Unit to assess or evaluate
the units performance
i.

Visitor/Client Logbook - a logbook where visitors and

clients sign

j.

Interview and Counseling Profile Form - is used to record

names of students who availed of the interview and
counseling service. It also shows students course, sex,
contact number and counseling remarks. This is kept with
strict confidentiality.

k. Exit Interview Form - is a questionnaire filled-out by the

graduating students and used by the counselor as guide in
conducting exit interview . The interview aims to help
them prepare for their Job Application Journey and future
career plans
B. Office Forms
a. Request of Materials, Equipment, Furniture and Fixtures
(to be attached to PPMP) - this form is prepared and
submitted together with the Annual Work and Financial
Plan. The units office supplies, materials, equipment
and other needs are reflected therein.
b. Inventory of Materials, Equipment, Furniture and
Fixtures (to be attached to MR Form) - an
acknowledgement receipt of all equipments received
from the administration which is under the employees
responsibility and accountability
c. Annual Work and Financial Plan - this presents the
units
Goals, Indicators, Strategies/Activities with
Quarterly Physical Targets
and corresponding
Expenditure Items
d. Quarterly Monitoring and Evaluation of Work and
Financial Plan - this form presents the units
accomplishments whether the targets indicated in the
AWFP are met
6. Appendices

A. Guidance Forms
Students Personal Data Sheet and Guide to Initial Interview
Call-slip
Reasons for Students Failures
Referral Slip
Logbook of Guidance Counselor
Evaluation of the Activity
Individual Performance Commitment and Review (IPCR)
Office Performance Commitment and Review
Visitor/Client Logbook
Interview and Counseling Profile Form
Exit Interview Form

B. Office Forms
Request of Materials, Equipment, Furniture and Fixtures
Inventory of Materials , Equipment, Furniture and Fixtures
Annual Work and Financial Plan
Quarterly Monitoring and Evaluation of Work and Financial Plan
GUIDANCE SERVICES UNIT
MINDANAO UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cagayan de Oro City
STUDENTS PERSONAL DATA SHEET AND INITIAL INTERVIEW FORM

Course/Major: ________________________ Student No. _________________ Date of Admission:

___________
Please Check your status:
_____ New Student
_____ Returnee
_____
Transferee
(PLEASE WRITE IN CAPITAL LETTERS)
Last Name
First Name
Middle Name
Date of Birth: ____________________________
Age: ____
Sex: ____ Cellphone
No:_________________
Email Address: ______________________________________ FB Account Name:
______________________
Home Address:
_____________________________________________________________________________
Present Address:
_________________________________________________________________________
Fathers Name: _________________________ Occupation: ____________________ Contact No.:
__________
Mothers Name: ________________________ Occupation: ____________________ Contact No.:
__________
Guardians Name: _______________________Occupation: ___________________
Contact No.:
__________
Name of High School Graduated:
_______________________________________________________________
Address: ____________________________________________________ No. of brothers: __ No. of
sisters: ___
=====================================================
=====================================
Please answer the following questions honestly:
1. Why did you choose this particular course?
__________________________________________________________________________________________

__________________________________________________________________________________________
__________________________________________________________________________________________
2. Briefly describe yourself:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. How would you describe your family? Please check below:
_________ a. A family with harmonious relationship among family members.
_________ b. A family having conflict with some family members
_________ c. A family with separated parents.
_________ d. A family with parents working abroad.
_________ e. Others
__________________________________________________________________________________________
4. Where do you live right now? Please check on the space provided:
_________at home _________ boarding house _________ relatives _________ friends
________others
5. Describe your living condition. Please check on the space provided:
_______a. conducive for studying
_______ b. not conducive for studying Why?
______________________
__________________________________________________________________________________________
================================DO NOT ANSWER BELOW THIS
LINE=============================
6. Describe your student life. Please check on the space provided:
________ Adjusting
________ Struggling
_______ Enjoying
_______ Excelling
Academically
________ Has Failing Grades
_______ Others _______________
Needs Help (What kind of help or assistance?)
____________________________________________________
7. What factors affect your studies or performance in the class? Please check
on the space provided:
___ a. physical defect or sickness
___ f. home problem
___
texting/chatting
___ b. influence of barkada
___ g. poor attitude
___ computer
games
___ c. poor study habit
___ h. lack of interest
___
surfing the net (FB., etc .)
___ d. love affair/broken hearted
___ I. too many outside ___ others
___________
___ e. financial problem
interests
___________
8. How will you cope such factor/s that affect your studies?
__________________________________________________________________________________________
__________________________________________________________________________________________
Counselor's Notes:
_________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
GUIDANCE SERVICES UNIT

Mindanao University of Science & Technology

Cagayan de Oro City

CALL SLIP

Name:_______________________________________________________
Course/Year & Section:
________________________Date:____________
Please drop by my office

_____ during your vacant period

_____ before going home at the end of the class
_____ at once, if possible
Time: A.M. - 9:00 - 11:00
P.M. - 1:30 - 5:00

_______________________
Guidance Counselor

MINDANAO UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cagayan de Oro City
Reasons for Students Failure
(Confidential)
Name: ___________________________________________
_______________
Subject:
___________________
Grade:
_________________________Date: ______

Course,
____

Yr.

&

Section:

Instructor:

Directions: Please check the possible cause/s or reason/s below which you
believe made you fail in
the subject

Possible Causes/Reasons for Failure

_______ Excessive academic load
background
_______ Frequent absences
not clear
_______ Illness or poor physical health
habits
_______ Concern over home problems
maladjustment
_______ Dislike classmates
_______ Too many outside interests
_______ Noisy environment or surroundings
_______ Lack of ability
_____________________________
_______ Failed to hand in a requirement

_______

Poor

academic

_______

Assignments

_______

Poor

_______

study

Emotional

_______ Financial worries

_______ Lack of interest
_______Others (specify)
_____________________________
________________
Students Signature

GUIDANCE SERVICES UNIT

MINDANAO UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cagayan de Oro City

REFERRAL SLIP
Name of Student Referred:
________________________________________________________________

Last Name

First Name

M.I.
Course/Year: ____________________________________ Sex: _________ Date:
____________________
Referred to : ________________________________________________________
Department/Unit: ____________________________________________________
Reason/purpose of referral:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Referred by:
___________________________________________
Signature Over Printed Name

MINDANAO UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cagayan de Oro City
STUDENT'S EVALUATION OF ACTIVITY

Title of Activity:
_____________________________________________________________
Date: _____________________ Time: _________________ Venue:
___________________
Department: ____________________ Course & Year Level:
__________________________ Sex: ________
In an effort to serve you better, we would appreciate it if you would
take a few minutes to evaluate honestly this activity by checking on the
column that corresponds to your rating. Your valuable responses will help
us improve in conducting more activities in the future. Thank you for your
help. It is greatly appreciated.
SAWS Director
Rating Scale:
3.5
2.5
1.5
1.0

Verbal Description

4.0
3.49
2.49
1.49

Excellent
Very Satisfactory
Satisfactory
Needs Improvement
CRITERIA

1. Relevance of the activity/appropriateness

2. Organization of the activity
3. Benefit to the students
4. Extent of audience participation
5. Audio and visual presentation
6. Attainment of objectives of the activity
7. Over- all impression of the activity
Comments/Suggestions/Recommendations:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Thank you!

Guidance Services Unit

MINDANAO UNIVERSITY OF SCIENCE AND TECHNOLOGY
INTERVIEW AND COUNSELING PROFILE FORM
COUNSELING

No
.

Dat
e

Name

Se
x

Course
and Year
Level

Conta
ct
Numb
er

GUIDANCE SERVICES UNIT

MINDANAO UNIVERSITY OF SCIENCE AND TECHNOLOGY
EXIT INTERVIEW FORM

Remarks

__________________________________________________________________________________
Last Name
First Name
Middle Name
Course/Major: _______ Sex: __ Contact Numbers: _____________ Date of Graduation: __________
Permanent Address: _________________________________________________________________
Email Address: _____________________________________________________________________
Please answer the following questions honestly. Use additional paper if
necessary:
1.
What
do
you
like
most
about
MUST?
__________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
2. What do you like least about MUST? _________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
3. Are you satisfied with the learnings that you get in your 4/5 years stay in MUST? Please Explain.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
4. Any suggestions for the improvement of any aspects in MUST?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5. How do you see yourself 5 to 10 years from now?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
6. OJT /Work Experiences:
Name of Company

Address

Skills Learned/
Enhanced

Duration of
Training/Work

Participation/Role/
Position

Distinction/
Awards Received

7. Co- Curricular/Extra-Curricular Activities:

Name of Organization/ Activity/Event

Date

8. Scholarships/Financial Assistance Availed : ____________________________________________

9. Distinction/Honors /Awards Received: ________________________________________________
__________________________________________________________________________________
--------------------------------------------------------------------------------------------------------------------------Counselor's Notes:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Interviewed by: ______________________________________ Date:_____________________