Republic of the Philippines

Department of Education
Region I
Division of Ilocos Sur

NAGTABLAAN NATIONAL HIGH SCHOOL

Sta. Lucia, Ilocos Sur

ANECDOTAL REPORT
Person Observed:__________________________________________
Observer:_____________________________________
Grade Level:________________________ S.Y.________________
Context: What was happening immediately before the behavior occurred?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________
Behavior: What behavior was manifested?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________
Effect: How did observer/others respond/react to the manifested behavior?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________
Outcome: How did person observed react/respond to others?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________
Recommendation:__________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
___________________________________________________________________________________________

Person Observed:__________________________________________
Observer:_____________________________________
Grade Level:________________________ S.Y.________________
Context: What was happening immediately before the behavior occurred?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________
Behavior: What behavior was manifested?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________
Effect: How did observer/others respond/react to the manifested behavior?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________
Outcome: How did person observed react/respond to others?
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________
Recommendation:__________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
_______________________________________
 Republic of the Philippines
Department of Education
Region I
Division of Ilocos Sur

NAGTABLAAN NATIONAL HIGH SCHOOL

Sta. Lucia, Ilocos Sur

STUDENT INFORMATION QUESTIONNAIRE

INSTRUCTIONS:
Your Guidance Counselor would like to get information about you as a student in order for her to give
you necessary assistance. In this connection you are hereby requested to answer this questionnaire honestly by
filling up/answering the following questions appropriate for you. Be assured that all the responses will be
handled with the highest level of confidentiality.
PERSONAL DATA

LRN:___________________________

NAME_______________________________________________________________________
LAST NAME FIRST NAME MIDDLE NAME
Date of Birth _____________________Place of Birth: _________________________________
Age: ____________Sex: _____________ Civil Status: _______________ Religion: ________
Citizenship: ______________________ Home Address: ___________________________
Present Address: _______________________________ Telephone/CP No. : ____________

HOME AND FAMILY BACKGROUND:

Father: ________________________________________ Date of Birth: _________________
Educational Attainment: __________________________ Occupation: _________________
Mother: _______________________________________ Date of Birth: _________________
Educational Attainment: __________________________ Occupation: __________________
No. of Brothers: ____________ No. of Sisters: _________ Position in the Family: _________
IF MARRIED, name of husband or wife: ___________________________
Date of Birth: _____________________ Age: _____________
Educational Attainment: _______________________ Occupation: ______________
PARENTS: ________Living together __________Temporarily separated
________Permanently separated ___________Father OFW
________Legally separated ___________Mother OFW
________Father w/ another partner ___________Mother w/ another partner

EDUCATIONAL BACKGROUND:

Grade/Year Level School Attended Inclusive Years of Attendance

Easiest Subject/s: ____________________________________________________________

Most Difficult Subject/s: _______________________________________________________
Plan after High School: ________________________________________________________
Membership in Organization/s: _________________________________________________
Special Interests:_____________________________________________________________
Special Skills/Talents: __________________________________________________________
What is your Ambition in Life?: _________________________________________________
What are the characteristics that describe you best?
______________________________________________________________________________

Present problems:______________________________________________________________

What is/are your greatest fear/s?__________________________________________________

______________________________________________________________________________

HEALTH INFORMATION

Chronic Illnesses:______________________________________________________________

Accidents experienced:__________________________________________________________

_________________________
Signature over Printed Name
 Republic of the Philippines
Department of Education
Region I
Division of Ilocos Sur

NAGTABLAAN NATIONAL HIGH SCHOOL

Sta. Lucia, Ilocos Sur

INTAKE INTERVIEW FORM

Student Name:______________________________ Student Number:_______________
Session Number:____________________ Date:________________
Action Taken on Previous Recommendation (if not the first session)
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________
Statement of the
Problem:__________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________
Goal of the
Session:___________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________
Technique used:________________________________________________________________
Outcomes:_________________________________________________________________________________
__________________________________________________________________
Plans to be Implemented:_________________________________________________________
______________________________________________________________________________
Recommendations:__________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________
 OFFICE FILE COPY

Republic of the Philippines

Department of Education
Region I
Division of Ilocos Sur
NAGTABLAAN NATIONAL HIGH SCHOOL
Sta. Lucia, Ilocos Sur

PASS SLIP

Name:____________________________________ Grade & Section:_______________

Inclusive dates of absence:_________________________
Cause of Absence:______________________________________________________________
______________________________________________________________________________

Remarks/ActionTaken:_______________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________

ADVISER’S COPY

Republic of the Philippines

Department of Education
Region I
Division of Ilocos Sur

NAGTABLAAN NATIONAL HIGH SCHOOL

Sta. Lucia, Ilocos Sur

PASS SLIP

Name:____________________________________ Grade & Section:_______________

Inclusive dates of absence:_________________________
Cause of Absence:______________________________________________________________
______________________________________________________________________________

Please readmit:
Excused: __________________________

Unexcused: ________________________

________________________
Guidance Designate
 Republic of the Philippines
Department of Education
Region I
Division of Ilocos Sur
NAGTABLAAN NATIONAL HIGH SCHOOL
Sta. Lucia, Ilocos Sur

LETTER TO PARENTS

_______________
_____________________________
_____________________________

Dear Mr. & Mrs._______________

With sincere concern over the welfare of yourson/daughter______________________

we wish to inform you that he/she:

___ has not reported to class since___________________________

___ is irregular in attendance
___has failed in_______________________________
___quarreled or made trouble in class
___is cutting classes frequently
___has often come late to his/her classes
___has shown disgraceful conduct
___(other reasons, specify)_________________________________

It is earnestly requested that you please come for a conference at the Guidance Office
on______________________ at ____________.

Your sincere and immediate attention to this matter is highly appreciated.

Very truly yours,

______________________________
Guidance Personnel/Guidance Designate
 Republic of the Philippines
Department of Education
Region I
Division of Ilocos Sur

NAGTABLAAN NATIONAL HIGH SCHOOL

Sta. Lucia, Ilocos Sur

CALL SLIP
_______________
Date

Name:_____________________________________________
Grade & Section:_____________________________________

PLEASE COME TO THE GUIDANCE OFFICE:

____ NOW (Show this slip to your teacher)

____during your vacant time
____on__________________ at__________________ (A.M./P.M.)

The undersigned would like to see you for:

____ INFORMATION ____ TESTING

____INTERVIEW ____ CONFERENCE
____ COUNSELING ____ OTHER___________________

______________________________
Guidance Counselor /Guidance Designate
 Republic of the Philippines
Department of Education
Region I
Division of Ilocos Sur
NAGTABLAAN NATIONAL HIGH SCHOOL
Sta. Lucia, Ilocos Sur

__________________
Petsa

PAGRAEMAN MI A NAGANNAK/AGAYWAN:

Sidadayaw kami nga mangipakaammo kadakayo nga daytoy anak tayo nga
ni______________________________ iti____________________ ( Grado ken Section) ket:

______saan nga sumsumrek iti klase na sipud__________________________

______irregular iti attendance na
______bagsak iti subject na nga________________________
______nakiringgor iti pada na nga estudyante
______kanayon nga ag-cutting classes
______kanayon a maladaw a sumrek iti klase na
______nangipakita ti saan a nasayaat a galad
______(sabali pay a rason)______________________________________

Gapu iti daytoy a banag, dawaten mi ti anusyo nga umay ditoy opisina makiyuman iti pannakaiwanwan
toy anak tayo into no________________________ iti oras ti_______________.
Yamanenmi unay iti panangipateg yo iti daytoy a surat ta agpaay metlaeng ti pagimbagan ti anak tayo.

________________________

__________________________

Noted:

_________________________
Principal