Learner enrollment-and-survey-form
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This document appears to be a learner enrollment and survey form containing sections for collecting information such as: 1) Student information including name, date of birth, gender, address. 2) Parent/guardian information including name, education level, employment status, contact details. 3) Household capacity and access to distance learning questions such as number of household members studying, available devices, internet access, preferred learning modalities, and challenges to learning. 4) Certification by parent/guardian allowing the education department to use student details and confirming information is true to the best of their knowledge.
Learner enrollment-and-survey-form
- 1. Page 1 of 16 A. GRADE LEVEL AND SCHOOL INFORMATION Enclosure No. 4 to DepEd Order No. s. 2020) LEARNER ENROLLMENT AND SURVEY FORM THIS FORM IS NOT FOR SALE Instructions: 1. This enrollment survey shall be answered by the parent/guardian of the learner. 2. Please read the questions carefully and fill in all applicable spaces and write your answers legibly in CAPITAL letters. For items not applicable, write N/A. 3. For questions/ clarifications, please ask for the assistance of the teacher/ person-in-charge. A1. School Year - A2. Check the appropriate boxes only No LRN With LRN A3. Returning (Balik-Aral) A4. Grade Level to enroll: A7. Last School Attended: A8. SchoolID: A11. School toenroll in: A12. School ID: A5. Last grade level completed: A9. School Address: A13. School Address: A6. Last school year completed: A10. School Type: Public Private FOR SENIOR HIGH SCHOOL ONLY: A14. Semester (1st /2nd ): A15. Track: A16. Strand (if any): B. STUDENT INFORMATION B1. PSA Birth Certificate No. (if available upon enrolment) B2. Learner Reference Number (LRN) B3. LAST NAME B4. FIRST NAME B5. MIDDLE NAME B6. EXTENSION NAME e.g. Jr., III (if applicable) B7. Date of Birth (Month/Day/Year) B8. Age B9. Sex B10. Belonging to Indigenous Male Peoples (IP) Female Yes No B14. Does the learner have special education needs? Yes No B15. If yes, please specify: B16. Do you have any assistive technology devices available at home? (i.e. scree Community/Indigenous Cultural Community B11. If yes, pleasespecify: B12. Mother Tongue: B13. Religion: reader, Braille, DAISY) Yes No B17. If yes, please specify : ADDRESS B18. House Number and Street B19. Barangay B20. City/ Municipality B21.Province B22.Region C. PARENT/ GUARDIANINFORMATION Father Mother Guardian C1. Full Name (surname, full name, middle name) C7. Full Maiden Name (surname, full name, middle name) C13. Full Name (surname, full name, middle name) C2. Highest Educational Attainment C8. Highest Educational Attainment C14. Highest Educational Attainment Elementary graduate Elementary graduate Elementary graduate High School graduate High School graduate High School graduate College graduate College graduate College graduate Vocational Vocational Vocational Masters/Doctorate degree Masters/Doctorate degree Masters/Doctorate degree Did not attend school Did not attend school Did not attend school C3. Employment Status C9. Employment Status C15. Employment Status Full time Full time Full time Part time Part time Part time Self-employed (i.e. family business) Self-employed (i.e. family business) Self-employed (i.e. family business) Unemployed due to ECQ Unemployed due to ECQ Unemployed due to ECQ Not working Not working Not working C4. Working from home due to ECQ? Yes No C10. Working from home due to ECQ? Yes No C16. Working from home due to ECQ? Yes No C5. Contact number/s (cellphone/ telephone) C11. Contact number/s (cellphone/ telephone) C17. Contact number/s (cellphone/ telephone) , For Learners with Special Education Needs / /
- 2. Page 2 of 16 D. HOUSEHOLD CAPACITY AND ACCESS TO DISTANCE LEARNING D1. How does your child go to school? Choose all that applies. walking public commute (land/ water) family-owned vehicle school service D2. How many of your household members (including the enrollee) are studying in School Year 2020-2021? Please specify each. D3. Who among the household members can provide instructional support to the childs distance learning? Choose all that applies. Kinder Grade 1 Grade 2 Grade 3 Grade 4 _ Grade 8 Grade 5 _ Grade 9 Grade 6 _ Grade 10 Grade 7 _ Grade 11 Grade 12 _ Others _ (ie college, vocational, etc) parents/ guardians elder siblings grandparents extended members of thefamily others (tutor, house helper) none able to do independent learning D4. What devices are available at home that the learner can use for learning? Check all that applies. cable TV radio non-cable TV desktop computer basic cellphone laptop smartphone none tablet others: D5. Do you have a wayto connect to the internet? Yes No (If NO, proceed to D7) D6. How do you connect to the internet? Choose all that applies. own mobile data own broadband internet (DSL, wireless fiber, satellite) computer shop other places outside the home with internet connection (library, barangay/ municipal hall, neighbor, relatives) none D7. What distance learning modality/ies do you prefer for your child? Choose all that applies. D8. What are the challenges that may affect your childs learning process through distance education? Choose all that applies. online learning modular learning television combination of face to face with other modalities radio others: _ lack of available gadgets/equipment insufficient load/ data allowance unstable mobile/ internetconnection existing health condition/s difficulty in independent learning conflict with other activities (i.e., house chores) high electrical consumption distractions (i.e., social media, noise from community/neighbor) others: I hereby certify that the above information given are true and correct to the best of my knowledge and I allow the Department of Education to use my childs details to create and/or update his/her learner profile in the Learner Information System. The information herein shall be treated as confidential in compliance with the Data Privacy Act of 2012. Signature Over Printed Name of Parent/Guardian Date For use of DepEd Personnel Only. To be filled up by the Class Adviser. DATE OF FIRST ATTENDANCE / /(Month/Day/Year) Grade Level Track (for SHS)