Sample Deped Anecdotal Record Form Download

Describe what the child did, not what you think the child is. Avoid labels like “bully,” “crybaby,” or “genius.” Instead: “Mark pushed the chair aggressively” (not “Mark is aggressive”).

Note what happened before the incident (antecedent). For example: “The incident occurred after the student was asked to return a borrowed pencil.”

Below is a complete, ready-to-use sample template. You can copy this into Microsoft Word or Google Docs and print.

Republic of the Philippines
Department of Education
Region [ ] – [School Division Name]
[School Name] sample deped anecdotal record form download

ANECDOTAL RECORD

Learner Information:
Name: _______________________________ Grade/ Section: ________
LRN (Learner Reference Number): _________________ Date of Birth: ____________
Gender: _____ Parent/Guardian: ______________________ Contact No.: ____________

Observation Details:
Date & Time of Incident: ____________________ Place: ____________________
Observer (Teacher/Staff): __________________ Subject/Activity: ____________ Describe what the child did , not what

Narrative Description of Incident (What was observed? Be factual, specific, and objective):

Interpretation / Analysis (Possible reason/s for the behavior, if known):

Action Taken (Check all that apply):
☐ Conference with learner
☐ Notified parent/guardian (Date: ______)
☐ Referred to Guidance Counselor (Date: ______)
☐ Developed behavior intervention plan
☐ Other: ________________________ Republic of the Philippines Department of Education Region

Follow-up / Recommendation:

Signature of Observer: ____________________ Date: ________
Signature of Parent/Guardian: _______________ Date: ________
Signature of Guidance Counselor (if applicable): _______________