Republic of the Philippines

Department of Education
Cordillera Administrative Region
Schools Division of Apayao
Pudtol District
MALIBANG ELEMENTARY SCHOOL

INTAKE SHEET

I. INFORMATION

A. VICTIM

Name: ___________________________________________________
Date of Birth: ___________________ Age: ______ Sex: ______
Grade and Section: __________________
Address: ___________________________________________________

Parents:

Mother: ____________________________ Age: _________

Occupation: _________________________
Address: _____________________________________________________
Contact Number: _____________________

Father: _____________________________ Age: ___________

Occupation: _________________________
Address: _____________________________________________________
Contact Number: _____________________

B. COMPLAINANT

Name: ______________________________________________
Relationship to Victim: _________________________________
Address: ____________________________________________
Contact Number: ______________________

C. RESPONDENT
C.1 If the respondent is a school personnel
Name:____________________________________
Date of Birth: ____________ Age: ___ Sex: __________
Designation/Position: ________________
Address: ___________________________
Contact Number: ____________________

c.2 If the respondent is a pupil

 Republic of the Philippines
Department of Education
Cordillera Administrative Region
Schools Division of Apayao
Pudtol District
MALIBANG ELEMENTARY SCHOOL

Name: ___________________________
Date of Birth: ___________________ Age: _____ Sex: _____
Grade & Section: ________________ Adviser: ___________________
Parents/Guardian
Mother: ____________________________________ Age: ___________
Occupation: _____________________________________
Address: ___________________________________________
Contact Number: ________________________________
Father: ____________________________________ Age: ___________
Occupation: _____________________________________
Address: ___________________________________________
Contact Number: ________________________________
c.3 If the respondent is not a pupil/school personnel
Name: ___________________________
Date of Birth: ___________________ Age: _____ Sex: _____
Grade & Section: ________________ Adviser: ___________________
Parents/Guardian
Mother: ____________________________________ Age: ___________
Occupation: _____________________________________
Address: ___________________________________________
Contact Number: ________________________________
Father: ____________________________________ Age: ___________
Occupation: _____________________________________
Address: ___________________________________________
Contact Number: ________________________________

II. DETAILS OF THE CASE

On April 19, 2023, at around ______ in the afternoon, Mrs. went to

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___________________________________________________________________________
___________________________________________________________________________
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 Republic of the Philippines
Department of Education
Cordillera Administrative Region
Schools Division of Apayao
Pudtol District
MALIBANG ELEMENTARY SCHOOL

III. ACTION/S TAKEN

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Prepared by:

________________________

Date: _________________