Republic of the Philippines

Department of Education
Region VI-Western Visayas
DOMINGO LACSON NATIONAL HIGH SCHOOL
Division of Bacolod City
Bacolod City

STUDENT’S INFORMATION
Grade and Section: GRADE 10 – TURQUOISE Adviser: ROSELYN O. NIPAY Date Administered: June 03, 2019
LRN: ________________________________

Name: _____________________________ ____________________________ _________________________

Family Name First Name Middle Name
Nickname: __________________________ Contact Number: ____________________________
Address: ___________________________________________________________________________________
Birth Date: _________________________ Birth Place: ___________________ Sex: ______________________
Distinguished Feature: ___________________________________________ Complexion: __________________
Age: ___________________________ Civil Status: __________________ Religion: ______________________
Father’s Name:
___________________________ _____________________________ ________________________
Family Name First Name Middle Name
Birth Date: ________________________ Age: _____________________ Occupation: ______________________
Highest Educational Attainment: _________________________________________________________________
Mother’s Complete Maiden Name:
___________________________ _____________________________ _________________________
Family Name First Name Middle Name
Birth Date: ________________________ Age: _____________________ Occupation: ______________________
Highest Educational Attainment: _________________________________________________________________
Family Income: (pls. check)
___P5,000 & below ___P15,001-P20,000 ___P30,001-P35,000
___P5,001-P10,000 ___P20,001-P25,000 ___P35,001-P40,000
___P10,001-P15,000 ___P25,001-P30,000 ___P40,000 above

Scholarship Grant: (pls. specify) _________________________________________________________________

Medical History of Illness or Operation:
___Asthma ___Diabetes ____Tuberculosis ___Hepatitis
Others (pls. specify): __________________________________________________________________________
Living Condition (House):
Materials: _____Light Materials ____Concrete _____Combination of light materials and concrete
Number of Members Currently Living in your Household include Yourself: ______________
Number of Bedrooms: _____________ Have owned toilet in the house: ___Yes ___No
Siblings:
Brothers: _____
Name: _______________________________________________________Age: __________ Status: _________
Name: _______________________________________________________Age: __________ Status: _________
Name: _______________________________________________________Age: __________ Status: _________
Name: _______________________________________________________Age: __________ Status: _________
Name: _______________________________________________________Age: __________ Status: _________
Sisters: _____
Name: _______________________________________________________Age: __________ Status: _________
Name: _______________________________________________________Age: __________ Status: _________
Name: _______________________________________________________Age: __________ Status: _________
Name: _______________________________________________________Age: __________ Status: _________
Name: _______________________________________________________Age: __________ Status: _________
EDUCATION
Elementary School Graduated: __________________________________________________________________
School Address: ________________________________________________Year Graduated: _______________
Residency Status for this School: (check appropriate box)
 Regular student of DLNHS who finished the year level during the last school year of attendance
 Continuing student of DLNHS who finished the year level during his/her last school year of attendance but
did not enroll in the next school year.
 Returnee (drop-out of DLNHS during the last school year of attendance)
 Transferee: Last School Attended:_________________________________________________________
School Address: _________________________________________________________________
Back Subject/s: __________________________________________________________________
 THE FAMILY- INDIVIDUAL- COMMUNITY- SCHOOL (FICS) TOOL
Refined by Michell L. Acoyong and Juna T. Flores

Name of Student: ____________________________________________ Date of Birth: _____________________

Year and Section: Grade 10- Turquoise Adviser: Roselyn O. Nipay Date Administered: June 01, 2018

I. FAMILY INCOME
How many are you in your family? _________
Father’s Occupation: ________________________________ Monthly Income: ______________________
Mother’s Occupation: _______________________________ Monthly Income: ______________________
How much does you family spend for the following monthly?
Food: __________________ Water: _____________________ Clothing: ____________
Electricity: ______________ Transportation: ______________ Fuel: _______________
School Allowance: _______ School Projects: ______________ Others: _____________
Do you work? __________ Why? ____________________________ How much do you earn? __________
What work? ___________________________ Since when? ____________________________________
Were you forced? ______________________ Effect on your schooling: ___________________________
Do you have a brother or sister who is out of school? ______ Why? _______________________________
Do you have a brother or sister who stopped schooling because he/she must work?
II. FAMILY STUCTURE AND RELATIONSHIP
Are both parents still alive? _____________ if not: _____mother _____father
Are your parents still living together? _________ if not. Why? __________________________________
With whom are you living? ____________ How do members of your family treat each other? ___________
III. FAMILY VALUING OF EDUCATION
Father’s highest educational attainment: _____________________________________________________
Mother’s highest educational attainment: ____________________________________________________
Educational attainment of siblings: _________________________________________________________
Do you have a brother or sister who has dropped out of school? __________________________________
Why? _______________________________________________________________________________
Do your parents check on or help with your assignments? _______________________________________
Do your parents attend PTA meetings and other school-related activities? __________________________
Do your parents personally and regularly get your report card? ___________________________________
Do your parents regularly confer with your teachers regarding your progress in school? ________________
Do your parents motivate you to deal well in school? ___________________________________________
IV. HEALTH AND NUTRITIONAL STATUS
Are you suffering from an illness? _______________ What illness? ________________________________
Since when have you been suffering from your illness? _________________________________________
Have you received any intervention (e.g. hospitalization, medication) _______________________________
Have you stopped schooling because of your illness? __________________________________________
V. ACADEMIC PERFORMANCES
What was your General Average last School Year? _____ Do you have failing grades? __ Subject: ______
How did you feel about failing? _____________________ Why did you fail: _________________________
What help did you receive from your teachers? ________________________________________________
VI. RELATIONSHIP WITH PEERS
Do you have a “barkada”? ___________ Is your “barkada” a positive influence on your schooling? _______
Have you done something you don’t want to gain the approval of your “barkada’? ____________________
If yes, what was the effect on you? ___________________________________________________
Have you been or felt bullied by your classmate/schoolmates? ___________________________________
What are your feelings being bullied? _________________________________________________
VII. COMMUNITY CONTEXT
How far is your home from school? _______________________
Is the road from your home to school passable by any means of transportation? ______________________
How much is the fare for the available means of transportation?
Is transportation any time? _______________ If not, when? _____________________________________
Do you feel safe traveling from home to school? _______ If not, why? ______________________________
What is the effect of your feeling not safe while travelling on your schooling? ________________________
Are there out of school youth in your barangay? ___________ Do you have friends among them? ________
Do they try to convince you to stop schooling ____________ What is your reaction? __________________
VIII. SCHOOL ENVIRONMENT
Do you enjoy being in school? ____ What makes you enjoy or not being in school? ____________________
Are you proud of your school? ____ What makes you proud or ashamed of your school? _______________
Is this your school of choice? _____ If not, why did you enroll here? _______________________________
Do you find the following adequate, conducive and supportive of your learning?
Classroom? ______________
Why/Why not? ________________________________________________________________________
Library? _________________
Why/Why not? ________________________________________________________________________
Laboratories? _____________
Why/Why not? ________________________________________________________________________
Clinic? __________________
Why/Why not? ________________________________________________________________________
Canteen? ________________
Why/Why not? ________________________________________________________________________
Activity Center ____________
Why/Why not? ________________________________________________________________________
Guidance Office? __________
Why/Why not? ________________________________________________________________________

Do you find all your teachers inspiring? ______________ If not, why? ___________________________________
Do you understand the school rules, policies and procedures concerning your accountabilities as a student? ______
Are the rules, policies, and procedures that you wish changed or scrapped? _______________________________
What are these rules, procedures?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

I truly answered all the questions with honesty.

________________________________________________
Signature over Printed Name

______________________________ ____________________________
ROSELYN O. NIPAY
Adviser Co- Adviser