Republic of the Philippines
Department of Education
REGION _____
SCHOOLS DIVISION OFFICE OF _______
_______ ELEMENTARY SCHOOL
NAME OF LEARNERS MODULE RETRIEVAL FORM
DATE OF (Week ___)
RETURN PARENT’S SIGNATURE
BOYS
1.
2.
3.
4.
5.
6.
GIRLS
1.
2.
3.
4.
5.
6.
TOTAL:
Prepared by: