HOME VISITATION NOTES
HVN Form 1
Students’ Name: ___________________________________________________________________________ Year Level:
___________________
Purpose of Visit:
Date of Visit:
________________________________
Yes No
The student lives in the same address. // //
Home Address: ____________________________________________________________
__________________________________________________________________________
Prevalent problems in the community (Please check all that apply):
/ / alcoholism / / gambling
/ / substance abuse / / smoking
/ / poor situation / / gang rivalry
/ / others:
Specify: __________________________________________________
The student lives with natural parents. // //
If no, with whom? __________________________________________________
Father is still alive. // //
Mother is still alive. // //
Father is working. // //
If yes, please specify: __________________________________________________
Mother is working. // //
If yes, please specify: __________________________________________________
No other people lives with the student’s family. // //
If no, who? __________________________________________________
The house is owned by family. // //
The lot is owned by family. // //
Religion of father/guardian: __________________________________________________
Religion of mother/guardian: __________________________________________________
No one is ill in the household. // //
If no, please specify: __________________________________________________
Student’s activity during the time of visit. Please check one.
/ / playing with siblings / / playing with friends
/ / doing school assignment / / running errands
/ / sleeping, taking rest / / watching TV
/ / Others (please specify): __________________________________________________
Other information that might be related to the purpose of the visit:
____________________________________________________________________________
____________________________________________________________________________________________________________
___________________________
Purok 7, San Isidro, Trento 8505, Agusan del Sur
317443@[Link]
(+639) 10-635-0709
Name and Signature of the Visiting Teacher: __________________________________________________
HOME VISITATION NOTES
HVN Form 2
Students’ Name: ___________________________________________________________________________ Year Level:
___________________
Purpose of Visit:
Date of Visit: ________________________________
Reasons for Absences:
Individual-Related:
Specify:
____________________________________________________________________________________________________________
___________
____________________________________________________________________________________________________________
__________________
____________________________________________________________________________________________________________
__________________
Family- Related:
Specify:
____________________________________________________________________________________________________________
___________
____________________________________________________________________________________________________________
__________________
____________________________________________________________________________________________________________
__________________
School-Related:
Specify:
____________________________________________________________________________________________________________
___________
____________________________________________________________________________________________________________
__________________
____________________________________________________________________________________________________________
__________________
Community-Related:
Purok 7, San Isidro, Trento 8505, Agusan del Sur
317443@[Link]
(+639) 10-635-0709
Specify:
____________________________________________________________________________________________________________
___________
____________________________________________________________________________________________________________
__________________
____________________________________________________________________________________________________________
__________________
Other-Related:
Specify:
____________________________________________________________________________________________________________
___________
____________________________________________________________________________________________________________
__________________
____________________________________________________________________________________________________________
__________________
Student’s activity during the time of visit. Please check one.
/ / playing with siblings / / playing with friends
/ / doing school assignment / / running errands
/ / sleeping, taking rest / / watching TV
/ / Others (please specify): __________________________________________________
Other information that might be related to the purpose of the visit:
____________________________________________________________________________
____________________________________________________________________________________________________________
___________________________
Agreement with the student/parents:
______________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________
____________________________________________________________________________________________________________
____________________________
________________________________________
__________________________________________
Name and Signature of the Visiting Teacher Name and
Signature of Parent/Guardian/Student
Purok 7, San Isidro, Trento 8505, Agusan del Sur
317443@[Link]
(+639) 10-635-0709