Republic of the Philippines

Department of Education
Region VI-Western Visayas
DIVISION OF SAGAY CITY
School: ________________________________________________________________________District: ____________________ Form 1 BULLYING
REPORT ON CASES OF ABUSE, VIOLENCE, EXPLOITATION, DISCRIMINATION, BULLYING OR PEER ABUSE AND OTHER RELATED OFFENSES
AS OF DECEMBER 31, 2017

Date/Plac Nature of Bullying Name of Perpetrator

Recommendatio
e of Name of Victim Age Sex /Position or relation to Age Sex Actions Taken Status
n
Incident Gender- Cyberbullyi victim
Physical Social Retaliation
based ng

Submitted by:
_______________________________________________
Signature Over Printed Name
______________________________________________
Position/Designation
 Noted:
_________________________________________ _________________________________________
ccd School Head PSDS
Republic of the Philippines
Department of Education
Region VI-Western Visayas
DIVISION OF SAGAY CITY
School: ________________________________________________________________________District: ____________________ Case Form 2 CHILD ABUSE
REPORT ON CASES OF ABUSE, VIOLENCE, EXPLOITATION, DISCRIMINATION, BULLYING OR PEER ABUSE AND OTHER RELATED OFFENSES
AS OF DECEMBER 31, 2017

NATURE OF ABUSE Name of Person Status

Date of Recommendatio
Name of Victim Age Sex Complained of /Position Age Sex Actions Taken (Resolved/pending/Referre
Incident or relation to victim
n d to other Agencies)
Physical Sexual Verbal/Psychological Others

Submitted by:
_______________________________________________
Signature Over Printed Name
______________________________________________
School Head (Designation)
 Noted:
ccd _________________________________________
PSDS