DUMALNEG NATIONAL HIGH SCHOOL

Dumalneg

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NAME: _____________________________________________________ TRACK/STRAND: _______________________

LRN: _______________________________________ SCHOOL YEAR: ___________________ SEME STER: _______
NAME OF COMPANY: _________________________________________________________________________________
COMPANY ADDRESS: _________________________________________________________________________________
PERIOD OF TRAINING: Date Started: ________________________ Date Finished: _____________________

PARTNERSHIP FOCAL OFFICE

DNHS Senior High School, Brgy. Poblacion, Dumalneg, Ilocos Norte
CP #. 09328694909
 APPROVAL SHEET

TO WHOM IT MAY CONCERN:

This Work Immersion Report and Handbook of _______________________________________

who is enrolled in ___________________________________________________________ and had undergone

Work Immersion at _________________________________________________________________________________

is hereby accepted and approved as partial fulfillment of the requirements for

graduation on this _________ day of ___________________________________, 20________.

Recommending Approval”

MERINA G. RAMOS
Senior High School Coordinator

APPROVED:

GASAT B. NIETO
School Industry Linkage Officer

VANESSA B. AGUINALDO
School Principal I
 TRAINEE’S INFORMATION SHEET

I. PERSONAL DATA

_____________________________________ __________________________________ ________________________________

Family Name Given Name Middle Name
Track: ________________________________ Strand: _______________________________________________________
Permanent Address: ________________________________________________________________________________
Present Address: ____________________________________________________________________________________
Telephone No.: ____________________________________ Cellphone No.: ________________________________
Date of Birth: _____________________________________ Age: _______________ Gender: __________________
Religion: _______________________ Civil Status: _____________ Height: _____(cm) Weight: ____(kg)
Blood Type: ______________________

II. FAMILY DATA

Father’s Name: ___________________________________________________ Occupation: ____________________

Date of Birth: _______________________________ Place of Birth : ______________________________________
Mother’s Name: ___________________________________________________ Occupation: ___________________
Date of Birth: _______________________________ Place of Birth : ______________________________________
Parent’s Address: ____________________________________________________________________________________
Telephone No.: ____________________________________Cellphone No.: _________________________________
Guardian: _____________________________________________________________________________________________
Your relation: ________________________________________________________________________________________
His/Her Address: ____________________________________________________________________________________
Telephone No.: ___________________________________Cellphone No.: __________________________________

IN CASE OF EMERGENCY, PLEASE CONTACT:

Name __________________________________________________________________________________________________
Relationship: _________________________________________________________________________________________
Address: _______________________________________________________________________________________________
Telephone No.: __________________________________Cellphone No.: __________________________________

I hereby declare that this information’s are true and correct.

__________________________________________
Signature
 WORK IMMERSION MEDICAL / DENTAL
EXAMINATION
Date Examined: ___________________________
Name of Trainee: _______________________________________________________ Strand: ___________________
Age : _________________ Sex: __________ Height: _____________________ Weight: _______________________
Heart Rate: ________/min Pulse Rate: _______/min Blood Pressure: ______________________
Allergy to (specify): _________________________________________________________________________________
Have or subjected to : ex. Palpitation, chest pain, etc. _________________________________________
Have or subjected to trouble with: ex. Diabetes, etc.. __________________________________________
Any condition af activity for medical reason : __________________________________________________

HEPA – B Vccinations: 1st Dose ________ 2nd Dose ______ 3rd Dose _______ Booster _________
Doctor’s Initial __________________________

PHYSICAL FINDINGS: (Please Check)

NORMAL ABNORMAL PLEASE DESCRIBE ABNORMALITY
____________ ________________ EYES/ VISION
____________ ________________ EARS
____________ ________________ NOSE
____________ ________________ THROAT
____________ ________________ LUNGS
____________ ________________ HEART
____________ ________________ BLOOD PRESSURE
____________ ________________ ABDOMEN
____________ ________________ HERNIA
____________ ________________ GENITALIA
____________ ________________ EXTREMETIES
____________ ________________ POSTURE/ SPINE
____________ ________________ URINE
____________ ________________ SKIN
____________ ________________ EMOTIONAL STABILITY
____________ ________________ Others (specify):

DENTAL FINDINGS:
____________ ________________ GUMS
____________ ________________ TEETH
____________ ________________ Others (specify):

Recommendations/ Restrictions : ________________________________________________________________

I hereby certify that I have examined this person and found him/her to be
physically and mentally fit to undergo Work Immersion Program.

RIZALDE M. ACOSTA, M.D.

Medical Officer
 COMPANY INFORMATION SHEET
Name of Company: ___________________________________________________________________________________

Address: _______________________________________________________________________________________________

Telephone No.: ________________________________________________________________________________________

Product Line/s: ________________________________________________________________________________________

Business Legal Form: _________________________________________________________________________________

Name/s of Owner: ____________________________________________________________________________________

Company Classification:
Local Government Unit

Cooperatives

Government Offices

Telecommunications

Educational Services

Research Laboratories

Health Care Services

Travel Services

Others (pls. specify) _________________________________________________

Total No. of Employees : _______________________________________

YOUR ASSGNMENT:
Division: ___________________________________________________________
Department: ___________________________________________________________
Section: ___________________________________________________________
Supervisor: ___________________________________________________________
Inclusive Dates of Training: ___________________________________________

CHANGE OF ASSGNMENT:
Division: ___________________________________________________________
Department: ___________________________________________________________
Section: ___________________________________________________________
Supervisor: ___________________________________________________________
Inclusive Dates of Training: ___________________________________________
 _______________________________________________________
(Name Of Company)

_______________________________________________________
(Address)

Certification and Clearance

TO WHOM IT MAY CONCERN:

This is to certify that the contents of this Work Immersion Handbook of

_______________________________________________ who had undergone Work Immersion
in this establishment are true and correct to the best of our knowledge and
belief.

Hence, a clearance has been granted to him/her from any property and
money responsibility and other accountabilities.

Given and signed this _______ day of ____________________________ 20_____ at

___________________________________________________________.

_____________________________________________________________
Printed Name of Work Immersion Partner Institution Supervisor
 THE WORK IMMERSION PROGRAM

Work Immersion refers to the subject of the Senior High School which
involves hands-on experience or work simulation in which the learners can
apply their competencies and acquired knowledge relevant to their strand to
achieve greater congruence between basic education and the nation’s
development targets.

This subject will provide learners with opportunities to:

1. Become familiar with the workplace;
2. For employment simulation; and
3. Apply their competencies in their areas of specialization/ applied
subjects in authentic environments.

To achieve the above objectives, Work Immersion is thus a requirement

for graduation from secondary education. Learners are immersed in actual
work environments such as workshops offices and laboratories in which their
prior training is relevant.
 SKILLS RATING SHEET
For each item listed within the competency bands, please CHECK (/) below the
evaluation most suited.
RATING SCALE:
RATING DESCRIPTIVE RATING
1 Unsatisfactory Performance does not meet the required standard. Major
improvements needed.
2 Fair Performance partially meets the required standard. Less than
satisfactory, could be doing better.
3 Average Performance has met the required standard. Can perform duties
with minimal supervision.
4 Outstanding Performance exceeds the required standard.

A. WORK IMMERSION SKILLS/ COMPETENCIES

COMPETENCIES/ TASK / DUTIES RATING

1 2 3 4
1 Organizational Skills. (filing, time management)
2 Data Entry (filling out forms, transcribing/ managing
documents, typing skills)
3 Language Skills (proficiency in English both oral and
written)
4 Social Interaction (ability to interact with people, customer
service, telephone usage)
5 Computer Skills (ability to use software like Microsoft
word, excel, power point)
6 Analytical/ Logical Thinking (ability to draw specific
conclusions from a set of general observations or from a set
of specific facts; able to synthesize information and ideas)
7 Critical Thinking Skills (ability to review different points
of view or ideas and make objective judgments, investigates
possible solutions to a problem, weighing the pros and cons)
8 Creative Thinking Skills (ability to generate new ideas,
create new image or designs, find new solutions to problems)
9 Decision-making Skills (ability to identify all possible
options, assess feasibility and choose the most viable option)
10 Planning Skills (ability to plan projects, events and
programs)
11 Ethical Skills (able to perform every tasks with proper
ethics)
12 Discipline Skills (ability to discipline himself/herself in the
workplace and ability to discipline people around him/her)
13 High Emotional Intelligence (shows high levels of self-
awareness, empathy and sensitivity to others)
 14 Collaboration Skills (ability to function in a multi-party
work environment)
15 Time Management (ability to perform all the tasks well
and utilize his/her time)
16 Interpersonal Skills (ability to develop good relationship
among other people.
17 Leadership Skills (ability to lead the group and to take
initiative in every tasks to be performed)
18 Self- confidence(ability to listen his/her inner voice and
have self -awareness
19 Psychological openness (willingness to allow oneself to be
influenced by other people and to share one’s idea openly)
20 Stress Management (ability to de-stress so that he/she can
still perform the job well
21 Negotiation Skills (ability to negotiate with others – both
co-workers and clients/customers)
22 Work Skills (handles the details of work assigned to
him/her)
23 Social Skills (shows respect and courtesy in dealing with
peers and superiors)
TOTAL
GENERAL TOTAL
Comments / Suggestions / Recommendations:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
____________

SUM Grade SUM Grade SUM Grade

Equivalent Equivalent Equivalent
92 100 75-74 91 57-56 82
91-90 99 73-72 90 55-54 81
89-88 98 71-70 89 53-52 79
87-86 97 69-68 88 51-50 78
85-84 96 67-66 87 49-48 77
83-82 95 65-64 86 47-46 76
81-80 94 63-62 85 45-44 75
79-78 93 61-60 84 43-42 74
77-76 92 59-58 83 41-1 73

______________________________ _______________________________________________
Date of Evaluation Name and Signature of Evaluator
Position/ Designation
B. BEHAVIOURAL SKILS/ COMPETENCIES

RATING
A. TEAMWORK 1 2 3 4
1 Consistently works with others to accomplish goals and
tasks.
2 Treats all team members in a respectful courteous manner.
3 Actively participates in activities and assigned tasks as
required.
4 Willingness to work with team members to improve team
collaboration on a continuous basis.
5 Considers the feedback and views of team members when
completing an assigned task.
6 Is capable of learning from and listening to co-workers.
B. COMMUNICATION
1 Actively listens to supervisor or co-workers.
2 Comprehends oral and written information.
3 Consistently delivers accurate information both written and
oral.
4 Reliably provides feedback as required, both internally and
externally.
C. ATTENDANCE AND PUNCTUALITY
1 Is punctual on a regular basis.
2 Reports regularly.
3 Informs supervisor in atimely manner when absenteeism
and tardiness occur.
D. PRODUCTIVITY / RESILIENCE
1 Consistently delivers quality results.
2 Ability to meet deadlines and manages time well.
3 Ability to multi task.
4 Ability to work around problems and obstacles ina stressful
situation in order to achieve the required tasks.
5 Fully understands the linkage or connection between
his/her task to previous, intervening and subsequent tasks.
6 Time management is effective and efficient.
7 Efficiently informs supervisor of any challenges and barriers
relevant to given task or assignment.
E. INITIATIVE / PROACTIVITY
1 Ability to complete assignments without being reminded by
his/her supervisors and/ or others
2 Successfully completes tasks independently and
consistently.
3 Seeks additional support when necessary.
4 Recognizes and takes appropriate action to effectively
 address problems and opportunities.
5 Engages in continuous learning.
6 Contributes new ideas and always seeking ways to improve
the department/organization.
F. JUDGEMENT / DECISION MAKING
1 Analyzes problems effectively.
2 Demonstrates the ability to make creative and effective
solutions to problems.
3 Demonstrates good judgement in handling routine
problems.
4 Manifests thoroughness and precise attention to details.
G. DEPENDABILITY / RELIABILITY
1 Ability to follow through and meet required deadlines.
2 Is personally accountable for his/her actions.
3 Adapts effectively to changes in the work environment.
4 Displays a consistent level of high performance.
H. ATTITUDE
1 Offers assistance willingly.
2 Make a positive contribution to morale.
3 Shows sensitivity to and consideration for other’s feelings.
4 Accepts constructive criticism positively.
5 Shows emotional maturity.
6 Shows poise, self -confidence and are always well-groomed.
7 Practices self-discipline in his/her work.
8 Shows appreciation and gratitude for any form of assistance
granted to him/her and/or by others.
9 Shows pride in work.
I. PROFESSIONALISM
1 Respects authorities.
2 Uses all tools, equipment and machines responsibly.
3 Follows all policies and procedures.
4 Performs tasks without much supervision.
5 Shows tact in dealing with different people he/she comes in
contact with.
6 Practices self-discipline in his/her work.
7 Maintains appropriate physical appearance in the workplace
in the work environment.
TOTAL
GENERAL TOTAL
GRADE EQUIVALENT:

SUM Grade SUM Grade SUM Grade

Equivalent Equivalent Equivalent
200 - 196 100 155 - 151 91 110 – 106 82
195 – 191 99 150 – 146 90 105 – 101 81
190 - 186 98 145 - 141 89 100 – 96 79
185 – 181 97 140 – 136 88 95 – 91 78
180 – 176 96 135 – 131 87 90 – 86 77
175 – 171 95 130 – 126 86 85 – 81 76
170 – 166 94 125 – 121 85 80 – 76 75
165 – 161 93 120 – 116 84 75 – 71 74
160 – 156 92 115 – 111 83 70 -1 73

RATED BY: CONFORME:

_______________________________________________________
____________________________________________
Work Immersion Partner Institution Supervisor Trainee

OVER ALL SUMMARY RATING SHEET

A. GRADE IN WORK IMMERSION

Transmuted Grade: __________ X .6 = ________________

B. GRADE IN BEHAVIORAL COMPETENCY

Transmuted Grade: __________ X .4 = ________________

C. OVER ALL RATING (A + B) = ________________

 TRAINEE SELF-ASSESSMENT

Answer the following questions briefly:

1. Were you given Orientation regarding the extent and scope of your Work
Immersion?
______________________________________________________________________________________________
______________________________________________________________________________________________

2. Who had given you Orientation?

_________________________________________________________________________________
_________________________________________________________________________________

3. Did the company provide you with assistance when you were in doubt of
your task? How?
_________________________________________________________________________________
_________________________________________________________________________________

4. Were you able to get along well with the employees of the company?
_________________________________________________________________________________
_________________________________________________________________________________

5. Do you think that your training is relevant to your strand/ specialization?

Why?
_________________________________________________________________________________
_________________________________________________________________________________

6. Did you learn additional skills and knowledge from your training?
_________________________________________________________________________________
_________________________________________________________________________________

7. Explain how you were benefitted from your training.

_________________________________________________________________________________
_________________________________________________________________________________

8. Was there effective supervision of your training? Explain.

_________________________________________________________________________________
_________________________________________________________________________________

9. Please give your recommendations / suggestions for the improvement of

the work immersion program of the school.
_________________________________________________________________________________
_________________________________________________________________________________
 DAILY LOG OF ACTIVITIES AND TRAINING HOURS

Name of Trainee: ______________________________________________________________________________

Station/Department: __________________________________________________________________________
For the Month of: ___________________________________________

AM PM SIGNATURE
DAY DATE
IN OUT IN OUT NATURE OF WORK OF
AUTHORIZED
PERSONNEL
1

10

11

12

13

14

15

__________________________________ _________________________________________
Signature of Student Signature of Authorized Personnel
 DUMALNEG NATIONAL HIGH SCHOOL
Dumalneg

Parents’ / Guardian’s Certification of Waiver / Permission

This is to certify that I am allowing _____________________________________________________________,

Name of the student
_________________________________________, to go for Work Immersion Program for a minimum of 80
hours Strand

starting on _____________________ until _______________________ at ____________________________________________

Company / Office Name
as partial fulfillment of the requirements for graduation from Secondary education.

It is understood that he/she abides by the rules and regulations that may be imposed by
the Supervisor / Staff-in-Charge for his/her welfare and safety.

I fully agree to waive any responsibility on the part of DUMALNEG NATIONAL HIGH
SCHOOL, ____________________________________________________________ ,the Work Immersion partner
Company / Office Name
institution and its representative/s, in case of any untoward incident that may happen to my

son/daughter during the duration of the work immersion program.

Conforme:

____________________________________________________
Signature over Printed Name of Parent / Guardian

_______________________________________________
Present Address

______________________
Contact Number
 DUMALNEG NATIONAL HIGH SCHOOL
Dumalneg

Parents’ / Guardian’s Certification to Withdraw the Trainee

from the Work Immersion Site

This is to certify that I am giving full consent and authority to the Work Immersion
Teacher

to withdraw / pull out my son / daughter _______________________________________________________________

Name of the Trainee / Student
in his/her Work Immersion Program due to involvement of activities, situations and cases that
may directly or indirectly affect both the parties implementing rules and guidelines of the Work
Immersion Program and the institution’s reputation in general.

It is understood that in cases like this, the TRAINEE will not be allowed to participate in
this Work Immersion Program thus, will just stay in school for a RESEARCH Project as partial
fulfillment to the requirements for graduation.

I fully understand the consequences imposed and will abide by to this agreement.

Certified true and correct:

_______________________________________________ _____________________________________________
Student’s Signature Over Printed Name Parent’s Signature Over Printed Name

Noted:

_________GASAT B. NIETO_______________ VANESSA B. AGUINALDO___

Work Immersion Teacher’s Signature Over Printed Name Principal’s Signature Over Printed Name
 DUMALNEG NATIONAL HIGH SCHOOL
Dumalneg

List of Tasks/ Activities During Work Immersion

Name of Student: ______________________________________________ Grade & Section: _______________________
Track: _________________ Strand: ____________________ Duration of Work Immersion: ___________________
School Industry Linkage Officer: __________________________________________ Contact No.: ________________
Work Immersion Techer: __________________________________________________ Contact No.: ________________

COMPETENCIES TASKS/ACTIVITIES TIME ACTUAL REMARKS

ALLOTMENT SCHEDULE
Organizational Filing,
Skills. Time management
Data Entry Filling out forms,
transcribing/ managing
documents, typing skills
Language Skills Proficiency in English both
oral and written
Social Ability to interact with
Interaction people, customer service,
telephone usage
Computer Ability to use software like
Skills Microsoft word, excel,
power point
Analytical/ Ability to draw specific
Logical conclusions from a set of
Thinking general observations or
from a set of specific facts;
able to synthesize
information and ideas
Critical Ability to review different
Thinking Skills points of view or ideas and
make objective judgments,
investigates possible
solutions to a problem,
weighing the pros and cons

Creative Ability to generate new

Thinking Skills ideas, create new image or
designs, find new solutions
to problems
Decision- Ability to identify all
making Skills possible options, assess
feasibility and choose the
most viable option
Planning Skills Ability to plan projects,
events and programs

Ethical Skills Able to perform every tasks

with proper ethics

Discipline Skills Ability to discipline

himself/herself in the
workplace and ability to
discipline people around
him/her.
High Emotional Shows high levels of self-
Intelligence awareness, empathy and
sensitivity to others.
Collaboration Ability to function in a multi-
Skills party work environment.

Time Ability to perform all the

Management tasks well and utilize time
effectively
Interpersonal Ability to develop good
Skills relationship among other
people.
Leadership Ability to lead the group and
Skills to take initiative in every
tasks to be performed
Self- confidence Ability to listen his/her
inner voice and have self –
awareness
Psychological Willingness to allow oneself
openness to be influenced by other
people and to share one’s
idea openly
Stress Ability to de-stress so that
Management he/she can still perform the
job well
Negotiation Ability to negotiate with
Skills others – both co-workers
and clients/customers
Work Skills Handles the details of work
assigned to him/her
Social Skills Shows respect and courtesy
in dealing with peers and
superiors

Certified true and correct:

__________________________________________ ___________________________________________
Student’s Signature Over Printed Name Parent’s Signature Over Printed Name

________GASAT B. NIETO_______ _____________________________________________

Work Immersion Teacher’s Signature Over Printed Name Industry Supervisor’s Signature Over Printed Name