R E P U B L I C O F T HE P H I L I P P I N E S

Department of Education
R E G I O N III
S C H O O L S D I VI S I O N O F F I CE O F B A T A AN
SDO B AT A AN – O R AN I A N N E X
PANTALAN LUMA ELEMENTARY SCHOOL

Report of Cases of Abuse, Violence, Exploitation,

Discrimination, Bullying or Peer Abuse and other related
offenses
School/ Division/ Region: _______________________________________
Period Covered :________________________________________
Person Submitting Report: _______________________________________
Designation : _______________________________________ Date: _________________

NAME AGE SEX NAME AGE SEX NATURE OF ACTION/S RECOMMEN

(Victims) (M/F) Respondent/s (M/F) COMPLAINT TAKEN DATIONS
 DEPARTMENT OF EDUCATION
INTAKE SHEET
I. INFORMATION

A. VICTIM:

Name :__________________________________________________________

Date of Birth : ______________________ Age :______ Sex : ____

Grade : ______________________ Adviser : ________________

Parents:

Mother : _____________________ Age : _________

Occupation : _____________________

Address and Contact Number : __________________________________

Father : ____________________ Age :_________

Occupation : _____________________

Address and Contact Number : __________________________________

B. COMPLAINT:

Name : __________________________________________________________

Relationship to Victim : _____________________________

Address and Contact Number : _____________________________

C. RESPONDENT:

C.1. If respondent is a School Personnel

Name : ________________________________________________________________

Date of Birth : ___________________ Age : _____ Sex :_____

Designation/Position : ____________________________________________________

Address and Contact Number : _____________________________________________

C.2. If respondent is a student

Name : ________________________________________________________________
 Date of Birth : ___________________ Age: ________ Sex:_______

Grade _________________________ Adviser: _________________________

Mother : ________________________________Age : _________

Occupation: __________________________________________

Address and Contact Number: ____________________________________

Father : _________________________________Age :____________

Occupation: _______________________________________

Address and Contact Number: ____________________________________

II. DETAILS OF THE CASE:

III. ACTION TAKEN:

1.
2.
3.
4.

IV. RECOMMENDATIONS:
1.
2.
3.

Prepared by:
__________________________________________
Name over Printed Name
__________________________________________
Designation
__________________________________________
Date