(Enclosure No. IA to DepEd Memorandum No. 59 s.

2015)

(To be submitted to the Division Office a week after the start of each school year)

SCHOOL - BASED REPORTS ON INCIDENTS OF BULLYING

School Year: 2022-2023

School: CLEMENTINO V. DIEZ MEMORIAL CENTRAL ELEMENTARY SCHOOL Classification (Public/Private: Public
Address: Roxas St., Brgy. Washington, Surigao City Level (Kindergarten, Elementary, Secondary): Elementary

Date/Place Nature of Bullying Victims Perpetrator Action Recommendation Status

of Incident Physical Social Gender- Cyber Retaliation Name Age Sex Name Age Sex Taken (Resolved/
Based Bullying (M/F) (M/F) Pending/Referred to
Other Agency
Octo Gym ∕ ∕ Lance 11 M Jhoner 12 M 1. The Both sides Resolved
ber Eviota ow victim was agreed to never
6, Flores taken to allow the
2022 the incident to recur
Assistant and to end the
Principal’s intimidation.
Office
with the
School
Guidance
Coordinat
or and
 adviser to
resolve
the
incident.
2. Upon
the
request of
the
perpetrat
or’s
parent,
they
would
meet with
the
victim’s
parent at
the
Assistant
Principal’s
Office to
clarify the
issues
involved.
Octo Insid ∕ ∕ Matt 9 M Lance 11 M The Provide Resolved
ber e the Andrie Eviota perpetrat guidance to the
18, scho F. or and perpetrator by
202 ol Sajulan his being kind to his
prem mother
2 classmates and
ises were schoolmates.
taken to
the
Assistant
Principal’
s Office
with the
adviser –
after the
adviser
 was
informed
by the
victim’s
mother of
the
incident.

Note: Bullying is perpetrated by a student against another student which may be:
Physical – unwanted Physical contact (punching, shoving, kicking, pushing, slapping, headlocks, etc.)
Social – refers to any deliberate, repetitive and aggressive social behavior intended to hurt or belittle an individual (name – calling, cursing, labeling, etc.)
Gender – Based – refers to any act that humiliates or excludes a person on the basis of perceived or actual sexual orientation and gender identity
Cyber Bullying – any bullying done through the use of technology or any electronic means (texting, email, chatting, online games, etc.)

Reviewed and Conformed by: Prepared by:

Date: ____________________________ Date: ____________________________

Name and Designation Name and Designation