DEPARTMENT OF EDUCATION
_____________________SCHOOL
INTAKE SHEET
[Link]
[Link]: Name: _______________________________
Date of Birth:_____________Age:_______Sex:_______Gr./Yr. and Section:_________Adviser:_____________________
Parents:
Mother:______________________________________ Age:____________
Occupation:___________________________________ Address:_____________________________________________
Father:_______________________________________ Age:____________
Occupation:___________________________________
Address and Contact Number:_________________________________________________________________________
[Link]: Name:_________________________
Relationship to the Victim:_________________________
Address and Contact Number:_______________________
[Link]:
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:___________
Gr./Yr. & Section:_____________________________________ Adviser:______________________________________
Parents/Guardians:
Mother:________________________________________________________________ Age:______________________
Occupation:______________________________Address & Contact Number:__________________________________
Father:_________________________________________________________________ Age:______________________
Occupation:______________________________Address & Contact Number:__________________________________
[Link] of the Case
__________________________________________________________________________________________________
[Link] Taken:
1._________________________________________________________________________________________________
2._________________________________________________________________________________________________
3._________________________________________________________________________________________________
[Link]:
1._________________________________________________________________________________________________
2._________________________________________________________________________________________________
Prepared by:
________________________________________
Signature Over Printed Name
________________________________________
Designation
________________________________________
Date
Noted:
________________________________________
Principal
REPORT ON CASES OF CHILDREN-AT-RISK (CAR)
SY 2017 – 2018
SCHOOL:____________________________________ Period Covered: _________________________
District:_____________________________________
CHILDREN – AT – RISK
No. of Students
Classification Action Taken Remarks
Male Female
1. Victims of Abuse
(sexual, physical, psychological, mental,
economic, and other mean)
2. Victim of neglect
3. Coming from a dysfunctional family or
without parent or guardian
4. Being member of a gang
5. Living in a community with a higher level
of criminality
6. Living in a situation of armed conflict
7. Committed a status Offense under
Section 57 of RA 9344, as amended
8. Prostituted children
9. Mendicant under PD 1563
10. Solvent / Rugby User
11. Others
Description of action taken by the school or division to alleviate the risk factors of the CAR:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Submitted by:
___________________________
School Head
