Annex “B”

DEPARTMENT OF EDUCATION
I. INFORMATION
A. VICTIM
Name: _________________________ DOB: ______________ Age: _____ Sex: ______
Grade/Yr. and Section: _________________ Adviser: ___________________________

Parents:
Mother: ____________________________ Age: ______ Occupation: _______________
Father: _____________________________ Age:______ Occupation: _______________
Address and Contact Number: _______________________________________________

B. COMPLAINANT
Name: ______________________________ Relationship to the Victim: _____________
Address and Contact Number: _______________________________________________

C. RESPONDENT
C-1. If the Respondent is a School Personnel
Name: _________________________ DOB: ______________ Age: _____ Sex: ______
Designation: _____________________
Address and Contact Number: _______________________________________________

C-2. If the Respondent is a student

Name: _________________________ DOB: ______________ Age: _____ Sex: ______
Grade/Yr. and Section: _________________ Adviser: ___________________________

Parents/Gurdian:
Mother: ____________________________ Age: ______ Occupation: _______________
Father: _____________________________ Age:______ Occupation: _______________
Address and Contact Number: _______________________________________________

II. DETAILS OF THE CASE

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III. ACTION TAKEN

1. _________________________________________________
2. _________________________________________________
3. _________________________________________________

IV. RECOMMENDATIONS
1. _________________________________________________
2. _________________________________________________
3. _________________________________________________

Prepared by:

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