STS Form 2A

Department of Education
Region ______________
Division of ________________
District of _______________
_______________________
1. Students Name: ____________________________________________ Age: ________ Sex: _____________
Address:______________________________________________________________________________________
Nationality __________________________________________________ Religion: _______________________
Ethnic Affiliation: ______________________________________________________________________________
Date of Birth ___________________________ Place of Birth: _______________________________________
Birth Registered

Yes

No

2. Has the student ever dropped-out of school?

Birth Registered

Yes

No

If yes, for how long: ____________________________________________________

What reason (s) ________________________________________________________
3. Distance from home to school: _______________ km.
Means of transportation to school:
Car

Motorized side car

Jeepney

Pedicab

Others ____________

4. Has any members of the family ever dropped f school?

Yes
No
5. Is the student receiving any type of financial assistance to attend school?
Yes
No
6. With whom does the student live?
Both Parents

Mother

Father

Others: ______________

Father

Others: ______________

7. Who helps the student in doing homework?

Both Parents

Mother

None
8.
Father
Information

Living

Mother
Deceased

Living

Deceased

Name:
Age:
Address:
Nationality:
Religion:
Language9s) dialect(s) spoken

9. Parental Marital Status:

Married

Live-in

Window

Annulled

Separated

Others (specify) ______________________________________________________________

10. List of members of the household including who have migrated, specify/check the information
needed.
Sex
Name of Household

Age

Relationship
to student

Migrated
How
Long?

Education
Enrolled/
Completed

Highest Grade/
NFE
Degree Completed Course Completed

Occupation
Full Time

Part Time

*Early childhood Education (service such as daycare and preschool)

11. Is the family a member of any community development organization?
Yes
No
12. Monthly Household Income
Below P1,000.00
P1,000-P2,500.00
P2,501-P5,000.00

P5,001-P8,000.00
P8,001-P16,000.00
Over P15,000.00

13. Information about the family:

A. The Family

D. Source of water supply

Owns house and lot

Rent house
Others, please specify _______

Faucet/Tap Water supply

Deep Well
Others, please specify _______

B. Type of House

E.

Concrete
Semi-Concrete
Others, please specify _______

Electricity
Kerosene lamp (gas)
Others, please specify _______

C. Type of Toilet
Flush
Pit
Water Sealed
No toilet
Others, please specify _______
14. Which of the following are available at home?
TV

Newspaper

Magazine

Radio

Book

Others, specify: ___________________________

Accomplished by: _________________________________

Date: __________________