Republic of the Philippines
Department of Education
Region II-Cagayan Valley
SCHOOLS DIVISION OF ISABELA
INTAKE SHEET (Child Abuse Cases and Bullying Incidents)
I. INFORMATION
A. VICTIM
Name: __________________________________ DOB: _____________ Age: ______ Sex: _______
Grade and Section: _________________ Adviser: ________________________
Parents:
Mother: ______________________________Age: ______ Occupation: _______________________
Father: _______________________________Age: ______ Occupation: _______________________
Address and Contact Number: ________________________________________________________
B. COMPLAINANT (Father, Mother or Guardian)
Name: ___________________________________ Relationship to Victim: ____________________
Address and Contact Number: ________________________________________________________
C. RESPONDENT
C-1. If Respondent is a School Personnel:
Name: __________________________________ DOB: _____________ Age: _____ Sex: _______
Designation: ___________________________________________________
Address and Contact Number: ________________________________________________________
C-2. If Respondent is a Student
Name: __________________________________ DOB: ______________Age: _____ Sex: _______
Grade and Section: _________________ Adviser: ________________________
Parents/Guardian:
Mother: ______________________________ Age: ______ Occupation: ________________
Father: _______________________________ Age: ______ Occupation: ________________
Address and Contact Number: ________________________________________________________
II. DETAILS OF THE CASE
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
III. CHECK ACTION TAKEN
Referred for Counselling to the School Guidance Counselor
Referred to Child Protection Specialist
Others, please specify: ________________________________________________________
IV. CHECK RECOMMENDATIONS
For psychosocial intervention as recommend by the School Guidance Counselor
Refer to CPC
Others, please specify: _______________________________________________________
Prepared by:
LILIBETH P. VITE
MT2/Teacher In-Charge
Republic of the Philippines
Department of Education
Region II-Cagayan Valley
SCHOOLS DIVISION OF ISABELA
CHILD PROTECTION COMMITTEE REPORT (Child Abuse Cases and
Bullying/Retaliation Incidents)
I. INCIDENT REPORT
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
II. ACTION/S TAKEN:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
III. Check box if victim is at risk
IV. RECOMMENDATION/REFERRALS (Check one)
Psychosocial intervention to the Division Guidance Counselor.
Referral to the LSWDO.
Referral to the PSWDO.
Referral to the PNP Women’s and Children’s Protection Help Desk.
Referral to the Chief of Police of the PNP Echague Station.
Referral to the Municipal Health Officer of Echague, Isabela.
Others, please specify: ______________________________________________________________
IN WITNESS HEREOF, we sign our names on this _____ day of ______________________________ at
_____________________________________.
1. Representative of Parents 2. Representative of Teachers
3. Representative of Students 4. Representative of Barangay (BCPC)
NOEMI C. URETA LILIBETH P. VITE
Guidance Counselor/Vice-Chairman MT2/Teacher In-Charge/Chairman
Republic of the Philippines
Department of Education
Region II-Cagayan Valley
SCHOOLS DIVISION OF ISABELA
Template “E”
CONFIDENTIAL
COUNSELING REPORT:
Name: ______________________________________________ Date: ____________________________
Age: _______ Grade and Section: _________________
Address: ___________________________________________________________
Father’s Name: ____________________________________________
Mother’s Name: ___________________________________________
Guardian’s Name: __________________________________________
Check status of learner/pupil (please check one):
( ) Victim
( ) Bully
( ) By-stander
A. FOR CHILD ABUSE
Incident report:
_________________________________________________________________________________
_________________________________________________________________________________
Recommendation:
_________________________________________________________________________________
_________________________________________________________________________________
Check box if victim is a risk and is recommended for Division Psychosocial Intervention.
B. FOR BULLYING INCIDENT.
Incident report:
_________________________________________________________________________________
Making the victim, bully, by-stander understand the negative consequences of bullying:
_________________________________________________________________________________
Formative and corrective measures recommended:
_________________________________________________________________________________
Activities recommended to address acts of bullying:
_________________________________________________________________________________
Recommendation for pro-social behavior:
_________________________________________________________________________________
Plan of Actions
( ) for Follow-up
( ) for Monitoring (tie up teachers/advisers).
( ) for Parent’s consultation/Home visitation.
NOEMI C. URETA
Teacher 3/Guidance Counselor
