MODIFIED LEARNER ENROLMENT SURVEY FORM S.Y. 2021-2022
Please take a few minutes to fill out the survey
Name of Student
*
First Name
Last Name
C2. FATHER Highest Education Attainment
*
No Formal Schooling
No Formal Schooling but able to read and write
Elementary Level
Elementary Graduate
High School Level
High School Level Graduate
After High School Education or Vocational (TechVoc/College/Post Grad)
C2. MOTHER Highest Education Attainment
*
No Formal Schooling
No Formal Schooling but able to read and write
Elementary Level
Elementary Graduate
High School Level
High School Level Graduate
After High School Education or Vocational (TechVoc/College/Post Grad)
C2. GUARDIAN Highest Education Attainment
*
No Formal Schooling
No Formal Schooling but able to read and write
Elementary Level
Elementary Graduate
High School Level
High School Level Graduate
After High School Education or Vocational (TechVoc/College/Post Grad)
C1O. Conditional Cash Transfer (4Ps) Beneficiary
*
YES
NO
D1. No. of Learners in a household (including the enrollee) studying in School Year 2021-2022.
*
1
2
3
4
5
6
7
8
Non-graded
Above 8
D2. Household members that can provide instructional supports to the child's distance learning
*
Parent/ Guardian Only
Parent/Guardian and Siblings
Parent/Guardian , Siblings & Grand Parent
Parent/Guardian, Siblings, Grand Parent & Other members of family
Parent/Guardian, Siblings, Grand Parent, Other members of family & Others
Siblings Only
Siblings & Grand Parent
Siblings, Grand Parent, Other members of family & others
Grand Parent Only
Grand Parent & Other members of family
Grand Parent, Other members of family & Others
Other members of family only
Other members of family and Other (tutor/helper)
Other (tutor/helper) only
Learner able to do independent learning
None
D3. Devices available at home that the learner can use for learning.
*
Television Only
Television and Cellphone
Television, Cellphone & Radio
Television, Cellphone , Radio & Desktop/Laptop
Cellphone only
Cellphone & Radio
Cellphone, Radio & Desktop
Radio Only
Radio & Desktop/laptop
Desktop/laptop only
Cellphone & Desktop/laptop
Tablet
None
D5. Way to connect to Internet
*
Mobile data only
Mobile data & broadband
Mobile data, broadband & computer shop
Mobile data, broadband, computer shop & other places
Broadband only
Broadband, computer shop & other places
Computer shop only
Computer shop and other places
Other places only
No internet available in the area
D6. Type of distance learning modality/ies prefer for the learner
*
Online learning only
Online learning & television
Online learning, television & radio
Online learning, television , radio & modular learning
Television Only
Television & radio
Television, radio & modular learning
Radio only
Radio & Modular Learning
Modular Learning (Printed)
Modular Learning (Digital)
Blended
D7. Challenges that may affect your child's learning process through distance education.
*
lack of available gadgets/ equipment only
lack of available gadgets/ equipment & insufficient load/ data allowance
lack of available gadgets/ equipment , insufficient load/ data allowance & unstable mobile/ internet connection
lack of available gadgets/ equipment , insufficient load/ data allowance, unstable mobile/ internet connection & existing health condition/s
lack of available gadgets/ equipment , insufficient load/ data allowance, unstable mobile/ internet connection, existing health condition/s & difficulty in independent learning
lack of available gadgets/ equipment , insufficient load/ data allowance, unstable mobile/ internet connection, existing health condition/s, difficulty in independent learning & conflict with other activities (i.e., house chores)
lack of available gadgets/ equipment , insufficient load/ data allowance, unstable mobile/ internet connection, existing health condition/s, difficulty in independent learning, conflict with other activities (i.e., house chores) & high electrical consumption
lack of available gadgets/ equipment , insufficient load/ data allowance, unstable mobile/ internet connection, existing health condition/s, difficulty in independent learning, conflict with other activities (i.e., house chores), high electrical consumption & distractions (i.e., social media, noise from community/neighbor)
insufficient load/ data allowance only
insufficient load/ data allowance & unstable mobile/ internet connection
insufficient load/ data allowance, unstable mobile/ internet connection & existing health condition/s
insufficient load/ data allowance, unstable mobile/ internet connection, existing health condition/s & difficulty in independent learning
insufficient load/ data allowance, unstable mobile/ internet connection, existing health condition/s, difficulty in independent learning & conflict with other activities (i.e., house chores)
insufficient load/ data allowance, unstable mobile/ internet connection, existing health condition/s, difficulty in independent learning, conflict with other activities (i.e., house chores), high electrical consumption & distractions (i.e., social media, noise from community/neighbor)
unstable mobile/ internet connection only
unstable mobile/ internet connection & existing health condition/s
unstable mobile/ internet connection, existing health condition/s & difficulty in independent learning
unstable mobile/ internet connection, existing health condition/s, difficulty in independent learning & conflict with other activities (i.e., house chores)
unstable mobile/ internet connection, existing health condition/s, difficulty in independent learning, conflict with other activities (i.e., house chores), high electrical consumption & distractions (i.e., social media, noise from community/neighbor)
existing health condition/s only
existing health condition/s, difficulty in independent learning & conflict with other activities (i.e., house chores)
existing health condition/s, difficulty in independent learning, conflict with other activities (i.e., house chores) & high electrical consumption
existing health condition/s, difficulty in independent learning, conflict with other activities (i.e., house chores), high electrical consumption & distractions (i.e., social media, noise from community/neighbor)
difficulty in independent learning only
difficulty in independent learning & conflict with other activities (i.e., house chores)
difficulty in independent learning, conflict with other activities (i.e., house chores) & high electrical consumption
difficulty in independent learning, conflict with other activities (i.e., house chores), high electrical consumption & distractions (i.e., social media, noise from community/neighbor)
conflict with other activities (i.e., house chores) only
conflict with other activities (i.e., house chores), & high electrical consumption
conflict with other activities (i.e., house chores), high electrical consumption & distractions (i.e., social media, noise from community/neighbor)
high electrical consumption only
high electrical consumption & distractions (i.e., social media, noise from community/neighbor)
only distractions (i.e., social media, noise from community/neighbor) only
E. Are you willing to allow your child to participate in limited face to face classes? If not, please select the major consideration
*
YES
Fear of Getting Infected of Corona Virus
Limited or no available transportation from home to school and vice versa
Existing Illness or health related concens
Helping in household chores
Helping in family business or working
Presence of Arm Conflict in the area
Other Reason, if any
Submit
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