Scribd
Upload
111 views

Intake Sheet: I. Information A. Victim

This intake sheet from Cabonga-an Elementary School in Cebu Province, Philippines collects information about a reported case. It records details about the victim, complainant, and respondent. If the respondent is a student or school staff, their personal information is documented. The form also notes the details of the case, any actions taken, and recommendations. The sheet is signed and dated by the preparing staff member.

Uploaded by

jovelyn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
111 views

Intake Sheet: I. Information A. Victim

This intake sheet from Cabonga-an Elementary School in Cebu Province, Philippines collects information about a reported case. It records details about the victim, complainant, and respondent. If the respondent is a student or school staff, their personal information is documented. The form also notes the details of the case, any actions taken, and recommendations. The sheet is signed and dated by the preparing staff member.

Uploaded by

jovelyn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 1

Republic of the Philippines

Department of Education
Division of Cebu Province
CABONGA-AN ELEMENTARY SCHOOL
Cabonga-an San Francisco, Cebu

INTAKE SHEET

I. INFORMATION
A. VICTIM

Name: ______________________________________ Birthdate: ____________ Age: __________ Sex: _________


Grade/Year Level and Section: __________________ Class Adviser: ___________________________________________

Parents:
Name of Father: ______________________________________________ Occupation: __________ Age: _________
Address: _____________________________________________________ Contact Number: _________________________
Name of Mother: _____________________________________________ Occupation: __________ Age: _________
Address: _____________________________________________________ Contact Number: _________________________

B. COMPLAINANT

Name: ______________________________________ Relationship to the Victim:


_______________________________
Address: _____________________________________________________ Contact Number: _________________________

C. RESPONDENT

C-1. If Respondent is a School Personnel


Name: ______________________________________ Birthdate: ____________ Age: __________ Sex: _________
Designation/Position: ________________________ Address: _____________________ Contact No.: ____________

C-2. If Respondent is a Student


Name: ______________________________________ Birthdate: ____________ Age: __________ Sex: _________
Grade/Year Level and Section: __________________ Class Adviser: ___________________________________________

Parents:
Name of Father: ______________________________________________ Occupation: __________ Age: _________
Address: _____________________________________________________ Contact Number: _________________________
Name of Mother: _____________________________________________ Occupation: __________ Age: _________
Address: _____________________________________________________ Contact Number: _________________________
II. DETAILS OF THE CASE:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
III. ACTION TAKEN
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________
4. _______________________________________________________________________________________
IV. RECOMMENDATIONS
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________

Prepared by:
________________________________
Signature Over Printed Name

________________________________
Designation/Date

You might also like