Republic of the Philippines

Department of Education
Region VI – Western Visayas
Division of Cadiz Coty
Cadiz District I – A
TIGLAWIGAN ELEMENTARY SCHOOL
So. Malunhao, Brgy. Tiglawigan, Cadiz City
School ID No.: 117541

BULLYING BEHAVIOR RECORD

1. Name of pupil being bullied and class group

MARK AARON S. ORBISO

____________________________________________________________________________ GRADE V - MOONSTONE
_______________________________

2. Name(s) and class(es) of pupil(s) engaged in bullying behavior

JASPHER Q. REMATA
____________________________________________________________________________ GRADE VI - PEARL
_______________________________
____________________________________________________________________________ _______________________________
____________________________________________________________________________ _______________________________
____________________________________________________________________________ _______________________________

3. Source of bullying concern/report

☐ Pupil concerned ☐ Parent ☐ Others _____________________
☐ Other pupil ☒ Teacher

4. Location of incidents
☒ Playground ☐ Corridor ☐ Others _____________________
☐ Classroom ☐ Toilets

5. Name of person(s) who reported the bullying concern

CRISEL LUNA L. AGUDO and ARRIANE GRACE T. CABAHUG

____________________________________________________________________________ TEACHERS
_______________________________

6. Type of bullying behavior

☒ Physical Aggression ☐ Name Calling ☐ Malicious Gossip
☐ Damage to Property ☐ Cyber-bullying ☐ Others (specify)
☐ Isolation/Exclusion ☐ Intimidation

7. Where behavior is regarded as identity-based bullying, indicate the relevant category.

☐ Homophobic ☐ Racist
☐ Disability/SEN related ☐ Others (specify)
___________________________

8. Brief description of bullying behavior and its impact

Jaspher Q. Remata, hit Mark Aaron S. Orbisio on the lips. As a result, the lips of Mark Aaron bled due to laceration.
_______________________________________________________________________________________________
_______________________________________________________________________________________________

9. Details of action taken

The parents were called for a closed-door meeting with the School Child Protection Committee.
_______________________________________________________________________________________________
_______________________________________________________________________________________________

_______________________________ _______________________________ Prepared by:

Pupil’s Signature Parent’s Signature

_______________________________ _______________________________ SHENA MAY R. MALAIT

_______________________________
Pupil’s Signature Parent’s Signature School Guidance Coordinator

Date Signed: ____________________ Date Signed: ____________________ Date Signed: ____________________