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Remarks:________________________________________________________________________________
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DON ROBERT B. ESTRELLA SR. NATIONAL HIGH SCHOOL
Nagsaag, San Manuel, Pangasinan
e Other (Specify)_______________
Contact No. ______________________________ n
Name of Student: __________________________ Gender:
d G Male G Female
st
Grade and Section:_________________________ Quarter:
e Ge1 2nd e 3rd 4th
G G G
Name of Adviser: _________________________ School
r Year:_______________________________
en n e
e e
nd n d n n
Date Type of Encounter Details of Concern Agreed
de Resolution
e d Signature
d d
Reported M er r e
e e
Dialogue a r Parent/Guardian:
r r r
_________________
Consultation l Teacher:
Home Visitation e M M __________________
Assembly/Forum M a M
a M M
al a l a a
Dialogue F le l e l Parent/Guardian:
l
_________________
Consultation e e e e Teacher:
e
Home Visitation m __________________
Assembly/Forum a F F
l Fe F e F F
Dialogue e em e me Parent/Guardian:
e
_________________
Consultation m
a m a m Teacher:
m
Home Visitation al l a __________________
a a
Assembly/Forum le e l
l l
e e e e
Dialogue Parent/Guardian:
_________________
Consultation
Teacher:
Home Visitation __________________
Assembly/Forum
Remarks:________________________________________________________________________________
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