Republic of the Philippines

PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

ANSWER SHEET FORM

For Family Functioning Checklist

Interview Date:______________

Name of the Child:_________________________ Gender __M___F

Date of Birth_____________________________
MM/DD/YYYY
Educational Attainment:_________________
Religion:____________________
Present Address:
____________________________________________________________________________
Contact Number (if
any):______________________________________________________________________
Source of Information (other than the
child):______________________________________________________
Relationship to the
Child:______________________________________________________________________

1. ___________(3) 8.___________(3) 15.__________(4) 22.___________(1)

2. ___________(2) 9.___________(3) 16.__________(2) 23.___________(1)
3. ___________(3) 10.___________(2) 17.__________(1) 24.___________(1)
4. ___________(2) 11.___________(3) 18.__________(1) 25.___________(1)
5. ___________(3) 12.___________(4) 19.__________(1) 26.___________(1)
6. ___________(3) 13.___________(3) 20.__________(1) 27.___________(1)
7. ___________(3) 14.___________(4) 21.__________(3) 28.___________(1)

Score: _______________
Interpretation:________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Scoring Procedure:
1. Add the weights (number in parenthesis) of all checked items.
2. Divide the sum by the number of checked items only to get the average or mean score.
3. The average or mean score is the child’s score in this checklist.

Interpretation of the Scores:

Score Rangers Description
1.00 to 1.50 Very Dysfunctional Family
1.51 to 2.50 Dysfunctional Family
2.51 to 3.50 Functional Family
3.51 to 4.00 Highly Functional Family
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

ANSWER SHEET FORM

For Child Functioning Checklist

Interview Date:______________

Name of the Child:_________________________ Gender __M___F

Date of Birth_____________________________
MM/DD/YYYY
Educational Attainment:_________________
Religion:____________________
Present Address:
____________________________________________________________________________
Contact Number (if
any):______________________________________________________________________
Source of Information (other than the
child):______________________________________________________
Relationship to the
Child:______________________________________________________________________

1. ___________(3) 8.___________(3) 15.__________(4) 22.___________(1)

2. ___________(2) 9.___________(3) 16.__________(2) 23.___________(1)
3. ___________(3) 10.___________(2) 17.__________(1) 24.___________(1)
4. ___________(2) 11.___________(3) 18.__________(1) 25.___________(1)
5. ___________(3) 12.___________(4) 19.__________(1) 26.___________(1)
6. ___________(3) 13.___________(3) 20.__________(1) 27.___________(1)
7. ___________(3) 14.___________(4) 21.__________(3) 28.___________(1)

Score: _______________
Interpretation:________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Scoring Procedure:
1. Add the weights (number in parenthesis) of all checked items.
2. Divide the sum by the number of checked items only to get the average or mean score.
3. The average or mean score is the child’s score in this checklist.

Interpretation of the Scores:

Score Rangers Description
1.00 to 1.50 Very Dysfunctional Family
1.51 to 2.50 Dysfunctional Family
2.51 to 3.50 Functional Family
3.51 to 4.00 Highly Functional Family
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

FAMILY FUNCTIONING CHECKLIST

Directions: Administer this checklist by interviewing the child or any of his significant others.
On a separate answer sheet, put a checkmark on the items that characterize the child’s family.

Begin here:
1. Child’s parents are hardworking.
2. Family head has a decent work occupation.
3. Family lives in a quiet wholesome neighborhood.
4. Parents value their children.
5. Parents try their best to provide a pleasant home atmosphere.
6. Parents maintain order in the family.
7. Family enjoys regular meals daily.
8. Family encourages the child to make decisions.
9. Parents have realistic expectations of their children.
10. Parents are consistent in their dealings with their children.
11. Parents are often in conflict with one another.
12. Parents are disappointed with each another.
13. Marriage is characterized by unpleasant relationships.
14. Child is often caught between the conflicts of the parents.
15. Family experiences marital conflicts.
16. Parents often make their children their objects of hostility.
17. Poor family conditions stimulate conflicts.
18. Father is a troublemaker.
19. The child often meets with frustrations in the family.
20. Parents have little trust in each other.
21. Family is often in pain.
22. Child feels left out and neglected.
23. Child is unable to develop a good image of himself.
24. Child is able to do things to take care of himself.
25. Child learns to adjust with the family lifestyle.
26. Child copes well in his environment.
27. Child accepts the restrictions/rules of his parents.
28. Child has a positive self-image.
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

ANSWER SHEET FORM

For Index Value of Judgement

Interview Date:

Name of the Child: Gender: ___M ___ F

Date of Birth: Age:
Educational Attainment: Religion:
Present Address:
Contact Number (if any):

1. 19. 37.
2. 20. 38.
3. 21. 39.
4. 22. 40.
5. 23. 41.
6. 24. 42.
7. 25. 43.
8. 26. 44.
9. 27. 45.
10. 28. 46.
11. 29. 47.
12. 30. 48.
13. 31. 49.
14. 32. 50.
15. 33. 51.
16. 34. 52.
17. 35. 53.
18. 36. 54.

Score:
Interpretation:

Scoring Procedure:
1. Refer to key to Correction to check the answers.
2. Count the number of correct answers.
3. The number of correct answers represents the child’s value judgement,vis-à-vis,his/her
level of discernment.

Score Rangers Level of

Discernment

Interpretation of the Scores: 1 to 11 Poor

12 to 22 Below Average
23 to 33 Average
34 to 44 Above Average
45 to 54 Superior
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

Index of Value Judgment

Directions: The following is a series of situations or activities about day-to-today living. Analyze
each situation or activity and determine if it is RIGHT or WRONG. Encircle either letter R or W to
represent RIGHT or WRONG , respectively.

Examples:
Throwing garbage anywhere
( Pagtapon ng basura kahit saan.) R W

Drinking clean water.

( Pag-inom ng malinis na tubig.) R W

Begin here:

1 .Reading a good book.

(Pagbasa ng magandang libro.) R W

2.Respecting one’s parents.

(Paggalang sa magulang.) R W

3.Running away from home and being astray. R W

(Paglayas ng bahay at magpalaboy-laboy.)

4.Smoking cigarettes.
(Paninigarilyo.) R W

5.Cutting classes.
(Di pagpasok sa ibang klase.) R W

6.Believing in God.
(Paniniwala sa Diyos.) R W

7.Destroying the properties of others.

(Pagsira ng gamit ng ibang tao.) R W

8.Cheating during examination

(Pangongopya sa panahon ng pagsusulit.) R W

9.Quarrelling with brothers and sisters.

(Pakikipag-away sa mga kapatid.) R W

10.Keeping the house clean.

(Pagpapanatiling malinis ang bahay.) R W

11.Shoplifting.
(Pagnanakaw sa tindahan /grocery/department store R W

12. Eating with dirty hands R W

(Pagkain na marumi ang kamay)
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

13. Treating someone cruelty R W

(Pang-aapi sa kapwa)

14. Cruelty to animals R W

(Pagmamalupit sa hayop)

15. Studying lessons well R W

(Pag-aaral ng mabuti)

16. Coming home late at night R W

(Paguwi ng gabing-gabi)

17. Playing very loud and disturbing music R W

(Pagpapatugtog ng malaks at nakakaistorbong musika)

18. Creating trouble in school R W

(Panggugulo sa eskwelahan)

19. Taking care of personal belongings R W

(Paga-alaga sa sariling gamit)

20. Going to church/place of worship and praying R W

(Pagsimba at pagdarasal)

21. Always coming to school late R W

(Pagiging huli sa klase)

22. Stealing R W
(Pagnanakaw)

23. Discussing bad and malicious things R W

(Pag-uusap tungkol sa mga bagay na masasama at paninira sa kapwa)

24. Keeping good friends R W

(Pagpapanatili sa mabubuting kaibigan)

25. Arguing and fighting with parents and elders R W

(Pakikipag-away sa mga magulang at matatanda)

26. Spending tuition fee R W

(Pagwaldas ng perang pambayad sa school)

27. Keeping oneself healthy R W

(Pagiging malusog)

28. Dropping out of school R W

(Pagtigil sap ag aaral)

29. Attempting to commit suicide R W

(Pagtangkang magpakamatay)
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

30. Obeying traffic rules R W

(Pagsunod sa batas trapiko)

31. Getting high grades in school R W

(Pagkakaroon ng mataas na marka)

32. Doing responsible household chores R W

(Paggawa ng gawaing bahay)

33. Killing the neighbour’s pet R W

(Pagpatay sa alagang hayop ng kapitbahay)

34. Driving while drunk R W

(Pagmamaneho ng lasing)

35. Doing a job well R W

(Pagtratrabaho ng maayos)

36. Disobeying parents R W

(Pagsuway sa utos ng magulang)

37. Taking prohibited drugs R W

(Paggamit ng bawal na gamot)

38. Coming home straight R W

(Pag-uwi diretso sa bahay)

39. Mother neglecting her family R W

(Pagpapabaya ni nanay sa pamilya)

40. Being dishonest R W

(Pandaraya)

41. Having regular exercise for good health R W

(Pag-eehersisyo para sa kalusugan)

42. Avoiding trouble R W

(Pag-iiwas sa gulo)

43. Beating someone R W

(Pananakit sa kapwa)

44. Helping to benefit a younger sibling R W

(Pagtulong sa ikabubuti ng nakababatang kapatid)

45. Volunteering in community work R W

(Patulong ng kusa o boluntaryong paggawa)

46. Staging a hold R W

(Panghohold-up)
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

47. Giving donations to charity R W

(Pagtulong sa mga nangangailangan)

48. Keeping the environment clean R W

(Pagpapanatiling malinis sa kapaligiran)

49. Disobeying traffic rules R W

(Paglabag sa batas trapiko)

50. Having a bad work habits R W

(Hindi maayos na pagtratrabaho)

51. Staying away from friends with bad influence R W

(Pag-iwas sa masasamang barkada)

52. Doing something good for somebody R W

(Paggawa ng mabuti para sa iba)

53. Does not want to work R W

(Ayaw magtrabaho/ tamad

54. Attending to the needs of the family R W

(Pagtugon sa pangangailangan ng pamilya)
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

CHILD FUNCTIONING CHECKLIST

Directrions: Administer this checklist by interviewing the child or any of his significant others. On a
separate answer sheet, put a checkmark on the items that characterized the child.

Begin here: The Child…

1. Has a positive attitude towards school.
2. Finds schoolwork demanding.
3. Wants to go school.
4. Is ashamed to go back to school.
5. Is willing to learn.
6. Is highly competitive.
7. Is knowledgeable about many topics.
8. Asks pertinent questions.
9. Answers questions willingly.
10. Makes alibis or excuses.
11. Remembers many events of childhood.
12. Is aware of the negative effects of prohibited drugs.
13. Is full of energy.
14. Finds hope in living.
15. Maintains good relationships with family and friends.
16. Often chooses to be alone.
17. Demonstrates low tolerance.
18. Is a run-away from home .
19. Is Daring and a risk taker.
20. Is easily provoked to fight.
21. Participates in religious activities.
22. Experiments with drugs and volatile substances.
23. Finds prohibited drugs and exciting.
24. Gets drunk so often.
25. Spends money in gambling.
26. Has a previous police/barangay record.
27. Gets away freely from violations.
28. Is involved in gangs or fraternities.
29. Is in and out of detention.
30. Has access to obscene materials.
31. Enjoy sex-oriented movies/films.
32. Spends money to watch X-rated movies /films.
33. Shows remorse/regret.
34. Wants to work hard to earn money.
35. Wants to work to help parents/family.
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

Questions:

1. Natapunan ng softdrink ang damit mo ng isang pasahero sa jeep. Ano ang gagawin mo at bakit?
2. Nilason ng inyong kapitbahay ang inyong alagang aso. Ano ang gagawin mo? Bakit?
3. Napatid mo ang alambre ng kuryente sa kalye habang nanunungkit ka ng mangga. Ano ang
gagawin mo? Bakit?
4. Nasira mo ang tubo ng gripo ng inyong kapitbahay. Ano ang gagawin mo? Bakit?
5. Napagtripan ng iyong barkada ang isang bagong salta sa barangay. Ano ang gagawin mo?
Bakit?
6. Tumanggi ang iyong girlfriend na makipagtalik sa iyo. Ano ang gagawin mo? Bakit?
7. Tumanggi ang iyong girlfriend na makipagtalik sa iyo. Ano ang gagawin mo? Bakit?
8. Pinahiya ng inyong kapitbahay ang iyong nanay. Ano ang gagawin mo? Bakit?
9. Pinilit ka iyong barkada na gumamit ng bawal na gamot. Ano ang gagawin mo? Bakit?
10. Siniraan ka ng iyong kasamahan sa barangay. Ano ang gagawin mo? Bakit?
11. Pinagalitan ka ng iyong magulang dahilsa masasama mong barkada. Ano ang gagawin mo?
Bakit?
12. Nagastos mo ang perang pambayad ng iyong nanay sa tindahan. Ano ang gagawin mo? Bakit?
13. Nasuklian ka ng sobra sa tindahan. Ano ang gagawin mo? Bakit?
14. Saksi ka sa pagnanakaw ng iyong kaibigan. Ano ang gagawin mo? Bakit?
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

Answers:
1. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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2. ______________________________________________________________________________
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3. ______________________________________________________________________________
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4. ______________________________________________________________________________
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5. ______________________________________________________________________________
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6. ______________________________________________________________________________
______________________________________________________________________________
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7. ______________________________________________________________________________
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8. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
9. ______________________________________________________________________________
______________________________________________________________________________
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

______________________________________________________________________________
______________________________________________________________________________
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10. ______________________________________________________________________________
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11. ______________________________________________________________________________
______________________________________________________________________________
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12. ______________________________________________________________________________
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13. ______________________________________________________________________________
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14. ______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

Circumstances of Referral

Name of referring party:

Address:
Contact Number:
Reason(s) for Referral:
Offense allegedly committed:
Date and Place where offense was allegedly committed:
Bunkhouse in Bahay Pag-asa
Date of Apprehension: Place:
Agency/Address:
Contact Number: Official Email Address:

Case:
Name of Victim:
Age:
Address:
Contact Number:
Relationship to the CICL:
Name of Accompanying Person:
Relationship:
Address:
Contact Number: Email Address:
 Republic of the Philippines
PROVINCE OF ROMBLON
PROVINCIAL SOCIAL WELFARE AND DEVELOPMENT OFFICE
PSWDO Building, Capaclan, Romblon, Romblon
Email Address: [email protected]; [email protected]

Relationship to the CICL:

Name of Victim:
Age:
Address:
Contact Number:
Relationship to the CICL:

Problem Presented
A. Law Enforcement Officer’s Report
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Child’s Version
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Initial Assessment and Recommendation Plan

____________________________________________________________________________________
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_____________________________
Name & Signature of the Client/Date

Interviewed by:

____________________________
Name & Signature of RSW
Lic. No.
Date: ______________________

Noted by:

__________________________________
Name & Signature of Supervisor
Lic. No.
Date: ______________________