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Republic of the Philippines

Department of Education
Region IV B MIMAROPA

____________________________________________
____________________________________________
Division Consolidated Reports on Incidents of Bullying and Retaliation
School Year ____________
DISTRICT: _________________________
Division: _________________________
Total Number of Public Schools:
Elementary:
Secondary:

Total Number of Private Schools:


Kindergarten:
Elementary:
Secondary:
TOTAL: _______

TOTAL: _______

NO.

NAME OF SCHOOL

SCHOOL
I.D.

PHYSICAL
NO. OF
MALE
VICTIMS

NO. OF
FEMALE
VICTIMS

NATURE OF BULLYING
PSYCHOLOGICAL
CYBER BULLYING
NO. OF
MALE
VICTIMS

NO. OF
FEMALE
VICTIMS

NO. OF
MALE
VICTIMS

NO. OF
FEMALE
VICTIMS

NO. OF BULLYING INCIDENTS


RETALIATION
NO. OF
MALE
VICTIMS

NO. OF
FEMALE
VICTIMS

TOTAL
NO. OF
MALE
VICTIMS

TOTAL
NO. OF
FEMALE
VICTIMS

GRAND
TOTAL

Submitted by:

Principal / Chairman - School CPPC

Republic of the Philippines


Department of Education
Region IV B MIMAROPA

____________________________________________
____________________________________________
Division Consolidated Reports on Incidents of Bullying and Retaliation
School Year ____________
DISTRICT: _________________________
Division: _________________________
Total Number of Public Schools:
Elementary:
Secondary:

Total Number of Private Schools:


Kindergarten:
Elementary:
Secondary:
TOTAL: _______

TOTAL: _______

Policy Submitted *
NO.

NAME OF SCHOOL

SCHOOL I.D.

School- Based Child Protection


Polciy with Anti- Bullying Policy

School- Based Child Protection


Policy without Anti- Bullying
Policy

Anti Bullying Policy Only

Submitted by:

Principal / Chairman - School CPPC

Republic of the Philippines


Department of Education
Region IV B MIMAROPA

____________________________________________
____________________________________________
Division Consolidated Reports on Incidents of Bullying and Retaliation
School Year ______________________
DISTRICT: _________________________
School I.D.: _________________________
School: _________________________
Address: _________________________
Classification (Public / Private) : _________________________
Level (kindergarten / Elementary / Secondary) : _________________________
Date of
Incident
(mm / dd /
yy)

NATURE
Physical

Psychologi
cal

Cyber
Bullying

VICTIMS
Retaliation

Name (Last Name, First Name,


M.I.)

RESPONDENTS
Age Sex (M / F)

Name (Last Name, First Name,


M.I.)

Action Taken

Age Sex (M / F)

Submitted by:

Principal / Chairman - School CPPC

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