Psychosocial Support for Face-to-Face Learning Modality Evaluation Form Learners' Response Te

This templates aims to collate and organize the responses of learners in the Psychosocial Support Evaluation Form (Pagsusuri
Pagbabalik Eskwela). This is primarily for the use of the TEACHERS who are expected to facilitate the psychosocial support a
evaluation form to learners (kinder teachers shall complete the form for their learners through a checklist format). This should b
to the SCHOOL HEAD within 5 days after the administration of the evalution forms to learners (i.e. note that there are 3

You may refer to OUA MEMO 00-1121-0125 (Dissemination of Psychosocial Activity Pack for Schools Participating in the Pilot
Face-to-Face Learnin Modality) for the details about the Psychosocial Support Acitivty Pack (Guidelines and Evaluation Form)

Intructions:
a) Download this form. DO NOT EDIT DIRECTLY ON THIS GOOGLE SHEET. Secure your own copy.
b) Collect learners' responses from the psychosocial evaluation form.
c) Encode learners' responses according to your grade level.
d) Submit the encoded and collated learners' responses to your School Head for submission.
e) If there are concerns regarding the template, contact DRRMS-MHPSS through e-mail at drrms+mhpss@deped.gov.ph
orm Learners' Response Template
Evaluation Form (Pagsusuri sa Sikososyal para sa
e the psychosocial support activities and administer this
ecklist format). This should be completed and submitted
rs (i.e. note that there are 3 schedules for administration).

ools Participating in the Pilot Implementation of the Limited

elines and Evaluation Form)

opy.

+mhpss@deped.gov.ph
 Evaluation
Form was Region Division School ID School Name Learners' Name LRN
Administered
 mga gusto imbis tulong tuwing pag-intindi sa
guro o ibang emosyon tulad napapakalma pangkatan o sa
na mang-agaw o may mga kamag-aral
nakatatanda ng saya, kapag nainis o mga gawain
makasakit sa pangangailanga na umiiyak o
 pumapasok sa Nagpapakita ng
Nakikipaglaro sa may nagawang pakikisalamuha
silid-aralan lalo sigla sa buong
mga kamag-aral mabuti (hal. sa mga bagong
na sa simula ng araw ng pasok
 Evaluation
Form was Region Division School ID School Name Grade Level Learners' Name
Administered
 damdamin, nararamdaman sa aking mga ang aking sarili humihingi ako o pagsubok,
LRN
mayroon akong tulad ng saya, kamag-aral, kapag ako’y galit ng tulong sa tumutukoy ako
ang aking mga ang mga May gana akong
makabalik sa aking pag-aaral aming paaralan n ko ang aking
kalakasan at damdamin ng pumasok muli sa
face-to-face na ang face-to-face sa pamamagitan sarili mula sa
kakayahan sa aking mga paaralan.
 Date of
Evaluation Form
was Region Division School ID School Name Grade Level
Administered to
Learners

August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio

August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
August 22, 2022 I I 300216 Lunec NHS 7-Bonifacio
 Naibabahagi ko
Kapag gusto
ang aking
kong ibahagi Kinikilala ko ang
nararamdaman
ang aking mga iba’t ibang
sa aking mga
damdamin, damdaming
kamag-aral,
Learners' Name LRN mayroon akong aking nadarama
kaibigan, guro,
mga guro at tulad ng saya,
magulang o
kamag-aral na lungkot, takot, at
tagapangalaga
pinagkakatiwala galit.
nang walang
an.
alinlangan.

Blanza, Jhondrix G. 134997150005 5 3 5

Calimag, Joshua A. 101547150001 4 4 5
Cansino. Gabriel J. 102290150041 2 3 4
Cendana, James Carl C. 102302150023 4 4 5
Cuario, Jan Josef P. 101545150031 5 3 3
Cuario, Jay-C A. 109403150250 4 3
Egipto, Rainiel 101547150004 4 4 4
Galzote, Randon Ralph D. 101545150002 5 4 4
Genorga, John Jerry D. 101545150003 4 5 5
Genoso, Gian J. 101341150024 4 4 4
Ilagan, Rhon Moises P. 101545150005 4 4 5
Jimenez Zaijan Lark E. 101545150035 4 3 3
Padilla, Lheyanbren B. 101545150009 5 4 3
Palaganas, Jay Mark C. 101547150029 5 3 4
Sarmiento, Jon Rhafael D. 101547150011 4 3 2
Tambanillo, Xyros C. 101545150040 2 2 4
Tesoro, Vincent G. 101547150012 2 3 5
Valencia, Jefferson G 101547150014 4 4 5
Albanio, Teffany Jade L. 101547150016 4 4 5
Atara, Scarlet T. 101545150014 4 5 4
Ballesteros, Honey D. 122731150028 4 5 2
Calimlim, Jerika Pearl V. 101545150016 4 5 5
Camahin, Sheena Lei D. 101545150015 4 4 5
Cancino, Jazelle J. 102302140014 3 5 3
Cuario, Maria Eileen Z. 101545150017 4 1 5
Decano, Jaina Mae C. 101545150043 4 5 4
De Loyola, Jhanna Rhane D. 101545150019 4 4 5
Del Rosario, Chennie Feb S. 101545150044 4 2 4
Delos Angeles, Ryzamae D. 101547150019 4 4 5
Docusin, Jhasmine P. 101883150068 3 2 4
Fortin, Erika C. 101545150059 4 4 3
Galliguez, Janine B 101545150060 4 4 4
Gomez, Loraine Abigail C. 101545150021 4 3 5
Historia, Jessa D. 101547150020 4 3 5
Inaldo, Girly Joy B. 101545150055 4 3 5
Naval, Nathalie Joyce C. 101545150022 4 4 5
Paglingayen, Shara Mae L. 101545150050 4 4 4
Vedana, Mary Rose M. 101545150026 4 5 4
Viernes, Iriesh T. 101545150028
 Kapag
Kapag may
Napapakalma ko nahihirapan ako
hinaharap akong Naipapakita ko
ang aking sarili sa pag-aaral, Inuunawa ko Masaya akong
suliranin o ang aking mga May gana akong
kapag ako’y humihingi ako ang damdamin makabalik sa
pagsubok, kalakasan at pumasok muli sa
nakararanas ng ng tulong sa ng aking mga face-to-face na
tumutukoy ako kakayahan sa paaralan.
dismaya at aking mga kamag-aral. klase.
ng mga paraan paaralan.
sama ng loob. kamag-aral o
para lutasin ito.
guro.

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 Napapanatiling
ligtas mula sa
Nakaiinam sa COVID-19 ang Naproprotektaha
aking pag-aaral aming paaralan n ko ang aking
ang face-to-face sa pamamagitan sarili mula sa
na klase. ng mga pagkakasakit.
ginagawang
pag-iingat.

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