Learner Enrollment Survey Form

If you're planning to survey learners online concerning their experience, direction, and areas for improvements, then the Learner Enrollment Survey Form is a good start for you! This is to serve as your template. You'll need to customize it with your own questions to fit your specific situation.

Questions for Learner Enrollment Survey Form

1.

School Year

The answer should be a text input.
2.

Grade Level to enroll

The answer should be a single choice:
    3.

    Last grade level completed

    The answer should be a single choice:
      4.

      Last school year completed

      The answer should be a single choice:
        5.

        Birth Certificate No

        The answer should be a number input.
        6.

        Learner Reference Number

        The answer should be a number input.
        7.

        FIRST NAME

        The answer should be a text input.
        8.

        MIDDLE NAME

        The answer should be a text input.
        9.

        LAST NAME

        The answer should be a date input.
        10.

        Date of Birth 

        The answer should be a single choice:
          11.

          Does the learner have special education needs? (i.e. physical, mental, developmental disability, medical condition, giftedness, among others)

          The answer should be a single choice:
          1. Yes
          2. No
          12.

          PARENT/ GUARDIAN INFORMATION

          The answer should be a single choice:
          1. Father
          2. Mother
          3. Guardian
          13.

          Name

          The answer should be a text input.
          14.

          Highest Educational Attainment

          The answer should be a single choice:
          1. Elementary graduate
          2. High School graduate
          3. College graduate
          4. Vocational
          5. Master’s/Doctorate degree
          6. Did not attend school
          15.

          Employment Status

          The answer should be a single choice:
          1. Full time
          2. Part time
          3. Self-employed (i.e. family business)
          4. Unemployed due to community quarantine
          5. Not working
          16.

          Contact Number

          The answer should be a phone number.
          17.

          Contact Email

          The answer should be a email input.
          18.

          How does your child go to school? Choose all that applies

          The answer should be a multiple choice:
          1. walking
          2. public commute (land/ water)
          3. family-owned vehicle
          4. school service
          19.

          What devices are available at home that the learner can use for learning? Check all that applies.

          The answer should be a multiple choice:
          1. cable TV
          2. radio
          3. non-cable TV
          4. desktop computer
          5. basic cellphone
          6. laptop
          7. smartphone
          8. tablet
          9. none
          20.

          Do you have a way to connect to the internet? 

          The answer should be a single choice:
          1. Yes
          2. No
          21.

          How do you connect to the internet? Choose all that applies

          The answer should be a multiple choice:
          1. own mobile data
          2. own broadband internet (DSL, wireless fiber, satellite)
          3. computer shop
          4. other places outside the home with internet connection (library, barangay/ municipal hall, neighbor, relatives)
          5. none
          22.

          What distance learning modality/ies do you prefer for your child? Choose all that applies

          The answer should be a multiple choice:
          1. online learning
          2. television
          3. radio
          4. modular learning
          5. combination of face to face with other modalities
          6. Other
          23.

          What are the challenges that may affect your child’s learning process through distance education? Choose all that applies

          The answer should be a single choice:
          1. lack of available gadgets/ equipment
          2. insufficient load/ data allowance
          3. unstable mobile/ internet
          4. connection
          5. existing health condition/s
          6. difficulty in independent learning
          7. conflict with other activities (i.e., house chores)
          8. distractions (i.e., social media, noise from community/neighbor)
          9. No or lack of available space for studying
          10. others
          24.

          I hereby certify that the above information given are true and correct to the best of my knowledge and I allow the Department of Education to use my child’s details to create and/or update his/her learner profile in the Learner Information System

          The answer should be a signature.

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