Department of Education

Region I
SCHOOLS DIVISION OFFICE I PANGASINAN
MACAYOCAYO ELEMENTARY SCHOOL
Bayambang

Name: _______________________________________________________ Grade & Section: 4-D

Please check all that you have observed about the learner.
STRENGTHS AND RESILIENCY FACTORS ACADEMIC PERFORMANCE INFORMATION
able to work independently cheating
can accept re-direction/criticism daydreams
considerate of others decrease in participation
cooperative difficulty retaining new or recent information
demonstrates constructive use of time does not take advantage of extra assistance offered/available
demonstrates desire/commitment to learn easily frustrated
displays good logic/reasoning & decision making failure to complete homework (repeatedly)
displays positive values (responsibility, honesty, equality, failure to complete in class assignments
caring)
exhibits leadership skills performing at or above ability
good communication skills performing significantly below ability
helps others poor test scores
is connected to and likes school and staff reading below grade level
participates in extra-curricular activities short attention span (explain specific behavior)
possesses good interpersonal skills sleeping in class
recognizes and respects appropriate boundaries & unprepared for class discussion/recitation
expectations
strives to achieve his/her best verbalized disinterest in academic performance
works well in a group Others (Please specify)
PHYSICAL ATTRIBUTES ATYPICAL BEHAVIOR/ILLICIT ACTIVITIES
complaining of nausea /stomach ache carrying large amounts of money
disoriented criticize others/self
fatigue denying responsibility, blaming others
food issues (example: refusal to eat lunch, etc.) disturbing other students
frequent cold-like symptoms easily distracted
frequently expressing concern with personal health expresses anger toward parent or other authority figure
glassy/bloodshot eyes expresses hopelessness, worthlessness, helplessness
noticeable change in weight (please explain) fighting/ hitting, pushing others
poor hygiene inappropriate dress (specify)
poor motor skills involvement in theft (student reported)
self-injury/self-harm lies
skin problems obscene language and/or gestures
slurred speech threatens or harasses others
unexplained physical injuries withdrawn/loner
unsteady on feet vandalism (student reported)
Others (Please specify) Others (Please specify)

________________________________ _______________________________
Signature of Learner Signature of Parent

LORENA T. DELFIN JAIME A. TAMONDONG

Adviser School Head