岡山白陵高等学校                                                                   調           査               書                                                  (本書開封無効)
                                                                                        卒業       令和                年   月      日 卒業・卒業見込       ※番号(岡山白陵記入)
   (ふりがな)
                                (                                       )
 
      生徒¹氏名
 
      平成                年        月       日生        性別
                 教科                                                                           保健        技術・                             特     記    事     項
                               国語        社会     数¹学        理科        音楽        美術                       外国語
             学年                                                                               体育        家庭
       評
                  1
 
                  2
       定
 学               3
 
 
 
 習
 
 
 
 の
 
 
 
 記                  学年                         学     習 活     動                                                              評                 価
        の総
        時合         1
 録     間的
        のな         2
        記学
        録習
                     3
 
 特                       学    活生        学
              内容                                                                                                          学年    欠席日数²        主な欠席理由(15日以上の場合）
                          級                校
 別                                   徒                                委         員      等
                          活                行
       学年               動    動会        事                                                                         出   1
 活
                                                                                                                       欠
 動          1
                                                                                                                       の
 の                                                                                                                         2
             2
                                                                                                                       記
 記
             3                                                                                                        録
 録
                                                                                                                            3
                       生基 の健 自自               責       創        ・思 自生 奉勤 公公 公公
              項目
                       活本    康                            意           い 然命             共
 行                         向 ・  主               任                 協      尊  労   正 徳
                       習的    体                            工           や 愛重             心
       学年
 動                    慣な 上力 律・               感       夫        力り 護・ 仕・ 平・ 心・
 
 の          1
 
 記
             2
 録
 
             3
 
 
 総                                                                                                    作         成
 合                                                                                                                                     令和          年         月           日
                                                                                                       年    月   日
 所
 見                                                                                                    記    入   者
 及                                                                                                                                                                          印
                                                                                                       氏    名   印
 び
 参
 考
 と                                                                                                                                                              中    学    校     長
                                                                                                       作         成
 な                                                                                                    責    任   者
 る                                                                                                    氏    名   印
 事                                                                                                                                                                         公 印
 項