Department of Education
Region X
Paste recent 2x2 ID
Division of Cagayan De Oro City
North II District Picture
BAYABAS ELEMENTARY SCHOOL
Zone 6, Bayabas, Cagayan de Oro City
PUPIL’S PERSONAL INFORMATION SHEET
(STRICTLY NO ERASURE. WRITE IN CAPITAL LETTERS ONLY)
PART I
LAST NAME FIRST NAME MIDDLE NAME NAME EXTENSION
(N/A if no middle name) (e.g. Jr.,II)
LRN No
SEX: AGE : DATE OF BIRTH : ________ PLACE OF BIRTH: _____________
NATIONALITY: RELIGION: HEIGHT: WEIGHT: BLOOD TYPE:
EMAIL ADDRESS: MOBILE& TELEPHONE NO.:
PRESENT ADRESS:
Lot No. Block No. Phase No. Street Brgy. Municipality/ City Province
PERMANENT ADRESS:
Lot No. Block No. Phase No. Street Brgy. Municipality/ City Province
FAMILY BACKGROUND:
FATHER’S NAME: EDUCATIONAL ATTAINMENT: OCCUPATION:
OFFICE & ADDRESS:
CONTACT NO.: _______________________________________________________
MOTHER’S NAME: EDUCATIONAL ATTAINMENT: OCCUPATION:
OFFICE & ADDRESS:
NO. OF SIBLINGS (BROTHER’S) (SISTERS)
CONTACT NO.: _______________________________________________________
GUARDIAN’S NAME: EDUCATIONAL ATTAINMENT: OCCUPATION:
OFFICE & ADDRESS:
CONTACT NO.: _______________________________________________________
FAMILY GROSS MONTHLY INCOME: (Please check)
Below PhP 10,000.00 PhP 40,000.00 – PhP 50,000.00
PhP 10,001.00 – PhP 20,000.00 PhP 40,000.00 – PhP 50,000.00
PhP 20,001.00 – PhP 30,000.00 Above PhP 100,000.00
PhP 30,001.00 – PhP 40,000.00
PART II
Height Weight Body Mass Index (BMI)
Bayabas Elementary School
School ID: 127959
Zone 6, Bayabas, Cagayan de Oro City
Department of Education
Region X
Division of Cagayan De Oro City
North II District
BAYABAS ELEMENTARY SCHOOL
Zone 6, Bayabas, Cagayan de Oro City
Do you have ailments?
(Attach medical record/certificate) Specify:
PART III
Are you a TRANSFEREE? YES NO
If YES, what school were you from?
Are you a BALIK-ARAL Student? YES NO
If YES, what school were you from?
What year did you stop studying?
What are your reasons for stopping?
Are you a REPEATER? YES NO
If YES, what school were you from?
What subjects did you fail?
What are your reasons for failing?
Are you a 4PS BENEFICIARY? YES NO
If YES, since what year?
Are you a student from ALIVE
(Arabic Language and Islamic Values Education)? YES NO
PUPIL’S PERSONAL INSIGHTS
My best subject is ________________________________________________________________________________.
My worst subject is _______________________________________________________________________________.
This year, I would like to learn ______________________________________________________________________.
Something new I would like to do this year is ___________________________________________________________.
My family can help me most this year by ______________________________________________________________.
My teacher can help most this year by ________________________________________________________________.
Parents’/Guardians’ Names ________________________________________________________________________
________________________________________________________________________
I think my strengths are ____________________________________________________________________________.
I think I need help with _____________________________________________________________________________.
This year, I would like to focus on ____________________________________________________________________.
I would like the teacher to know that ___________________________________________________________________.
PSYCHOSOCIAL ADJUSTMENT NEEDS OF GRADE 6 PUPILS
Talents/Skills: _____________________________________________________________________________________
Average grade for: (GRADE 5 Grade)
1st Quarter __________
2nd Quarter __________
3 Quarter
rd
__________
Bayabas Elementary School
School ID: 127959
Zone 6, Bayabas, Cagayan de Oro City
Department of Education
Region X
Division of Cagayan De Oro City
North II District
BAYABAS ELEMENTARY SCHOOL
Zone 6, Bayabas, Cagayan de Oro City
4th Quarter __________
PSYCHOSOCIAL ADJUSTMENT NEEDS
Directions: Please indicate the extent to which each statement applies to you by marking the box [x] that corresponds to your
appropriate response. Kindly follow the numerical guide below:
4 – Always
3 – Very often
2 – Sometimes
1 – Never
COGNITIVE 4 3 2 1
1. In school, I do not have a chance to learn things that are interesting for me.
2. I feel that I do not achieve anything from doing school work.
3. I do not enjoy staying in school because I get bored from studying the same
lessons repeatedly.
4. Most of my subjects are difficult.
5. I feel I cannot concentrate on my studies.
6. My school do not give me enough chance to discover new things.
7. I have too many assignments which I find impossible to finish.
8. I worry about examinations.
9. I find it difficult to adjust to the way our subjects are taught.
10. I think our lessons will be useless in real life situations.
EMOTIONAL 4 3 2 1
1. I do not feel safe when I am inside the school.
2. I enjoy being the center of attention.
3. I am not capable of making simple choices.
4. I do not care about the needs of others.
4 3 2 1
5. I do not feel emotionally attached or close to my schoolmates.
6. I feel nervous when I talk in front of many people.
7. I feel depressed sometimes even if there is no reason to feel depressed.
8. I feel like an outsider when I am at school.
9. It is hard for me to control my emotions.
10. I easily get irritated.
SOCIAL 4 3 2 1
1. I do not like going out with other people.
2. I do not feel comfortable when I am with other people.
3. I wish people would leave me alone.
4. I feel shy whenever I meet new people.
5. I do not make the first move to meet new people.
6. I find it difficult to make friends with the opposite sex.
7. I would choose to have a few close friends than to be a part of a clique
(barkada).
8. I am not interested in meeting people.
9. I do not enjoy attending parties and social gatherings.
10. I find it difficult to start a conversation with a stranger.
I. PSYCHOSOCIAL ADJUSTMENT NEEDS FROM SOCIAL RELATIONS
Directions: Please indicate the extent to which each statement applies to you by marking the box [x] that corresponds to your
appropriate response. Kindly follow the numerical guide below:
Bayabas Elementary School
School ID: 127959
Zone 6, Bayabas, Cagayan de Oro City
Department of Education
Region X
Division of Cagayan De Oro City
North II District
BAYABAS ELEMENTARY SCHOOL
Zone 6, Bayabas, Cagayan de Oro City
4 – Always
3 – Very often
2 – Sometimes
1 – Never
TEACHERS 4 3 2 1
1. I am afraid of my teachers.
2. I feel very upset when called to recite unexpectedly.
3. My teachers do not understand how I feel.
4. I have a crush with a teacher.
5. I feel bad when teachers show favoritism.
6. Some of my teachers use unfriendly words and does not think about how I feel
about it.
7. Teachers keep feelings of dislike or anger towards students.
8. I find it difficult to show respect to some teachers.
9. I find it hard to show my teachers who I really am.
10. I find it hard to share my personal problems to teachers.
PEERS (Classmates, schoolmates) 4 3 2 1
1. I do not trust my classmates and schoolmates.
2. I find it hard to hang out or mingle with peers.
3. I feel that my peers are better than me.
4. I feel that I don’t belong in the group.
5. I find it hard to listen to others.
6. I find it difficult to get peers to listen to me.
7. I cannot cope up financially with my friends.
8. I find it difficult to accept failure.
9. I always hurt other people’s feelings.
10. I find it hard to ask help from my peers.
PARENTS 4 3 2 1
1. I live with only one of my parents.
2. I live with a guardian and not with any one of my parents.
3. My life at home is unhappy.
4. My parents always criticize and judge me.
5. I cannot talk about my problems to my parents.
6. I feel unwanted in the family.
7. My parents are making unreasonable demands.
8. My parents are always fighting.
9. My parents do not have time for me.
10. My parents do not listen to me.
SIBLINGS (Brothers, sisters) 4 3 2 1
1. My brothers and sisters receive more support than I do.
2. I do not feel that my siblings love me.
3. I do not trust my brothers and sisters.
4. My siblings and I fight with each other.
5. I cannot talk about my problems to my siblings.
6. I have more household chores than they have.
7. I wish I had no brothers and sisters.
8. I wish I have nice personality like them.
9. I wish I were loved and wanted like them.
10. My brothers and sisters have no time for me.
Accomplished by:__________________________________________ Date of Submission:
Bayabas Elementary School
School ID: 127959
Zone 6, Bayabas, Cagayan de Oro City
Department of Education
Region X
Division of Cagayan De Oro City
North II District
BAYABAS ELEMENTARY SCHOOL
Zone 6, Bayabas, Cagayan de Oro City
(SIGNATURE OVER PRINTED NAME)
Thank you.
Bayabas Elementary School
School ID: 127959
Zone 6, Bayabas, Cagayan de Oro City
