Republic of the Philippines

Department of Education
Region II-Cagayan Valley
SCHOOLS DIVISION OF ISABELA

INTAKE SHEET (Child Abuse Cases and Bullying Incidents)

I. INFORMATION
A. VICTIM
Name: __________________________________ DOB: _____________ Age: ______ Sex: _______
Grade and Section: _________________ Adviser: ________________________
Parents:
Mother: ______________________________Age: ______ Occupation: _______________________
Father: _______________________________Age: ______ Occupation: _______________________
Address and Contact Number: ________________________________________________________

B. COMPLAINANT (Father, Mother or Guardian)

Name: ___________________________________ Relationship to Victim: ____________________
Address and Contact Number: ________________________________________________________

C. RESPONDENT
C-1. If Respondent is a School Personnel:
Name: __________________________________ DOB: _____________ Age: _____ Sex: _______
Designation: ___________________________________________________
Address and Contact Number: ________________________________________________________

C-2. If Respondent is a Student

Name: __________________________________ DOB: ______________Age: _____ Sex: _______
Grade and Section: _________________ Adviser: ________________________
Parents/Guardian:
Mother: ______________________________ Age: ______ Occupation: ________________
Father: _______________________________ Age: ______ Occupation: ________________
Address and Contact Number: ________________________________________________________

II. DETAILS OF THE CASE

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

III. CHECK ACTION TAKEN

Referred for Counselling to the School Guidance Counselor
Referred to Child Protection Specialist
Others, please specify: ________________________________________________________

IV. CHECK RECOMMENDATIONS

For psychosocial intervention as recommend by the School Guidance Counselor
Refer to CPC
Others, please specify: _______________________________________________________

Prepared by:
LILIBETH P. VITE
MT2/Teacher In-Charge
 Republic of the Philippines
Department of Education
Region II-Cagayan Valley
SCHOOLS DIVISION OF ISABELA

CHILD PROTECTION COMMITTEE REPORT (Child Abuse Cases and

Bullying/Retaliation Incidents)
I. INCIDENT REPORT
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

II. ACTION/S TAKEN:

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________

III. Check box if victim is at risk

IV. RECOMMENDATION/REFERRALS (Check one)

Psychosocial intervention to the Division Guidance Counselor.

Referral to the LSWDO.
Referral to the PSWDO.
Referral to the PNP Women’s and Children’s Protection Help Desk.
Referral to the Chief of Police of the PNP Echague Station.
Referral to the Municipal Health Officer of Echague, Isabela.
Others, please specify: ______________________________________________________________

IN WITNESS HEREOF, we sign our names on this _____ day of ______________________________ at

_____________________________________.

1. Representative of Parents 2. Representative of Teachers

3. Representative of Students 4. Representative of Barangay (BCPC)

NOEMI C. URETA LILIBETH P. VITE

Guidance Counselor/Vice-Chairman MT2/Teacher In-Charge/Chairman
 Republic of the Philippines
Department of Education
Region II-Cagayan Valley
SCHOOLS DIVISION OF ISABELA

Template “E”
CONFIDENTIAL
COUNSELING REPORT:

Name: ______________________________________________ Date: ____________________________

Age: _______ Grade and Section: _________________
Address: ___________________________________________________________
Father’s Name: ____________________________________________
Mother’s Name: ___________________________________________
Guardian’s Name: __________________________________________

Check status of learner/pupil (please check one):

( ) Victim
( ) Bully
( ) By-stander

A. FOR CHILD ABUSE

 Incident report:
_________________________________________________________________________________
_________________________________________________________________________________

 Recommendation:
_________________________________________________________________________________
_________________________________________________________________________________

Check box if victim is a risk and is recommended for Division Psychosocial Intervention.

B. FOR BULLYING INCIDENT.

 Incident report:
_________________________________________________________________________________
 Making the victim, bully, by-stander understand the negative consequences of bullying:
_________________________________________________________________________________
 Formative and corrective measures recommended:
_________________________________________________________________________________
 Activities recommended to address acts of bullying:
_________________________________________________________________________________
 Recommendation for pro-social behavior:
_________________________________________________________________________________
 Plan of Actions
( ) for Follow-up
( ) for Monitoring (tie up teachers/advisers).
( ) for Parent’s consultation/Home visitation.

NOEMI C. URETA
Teacher 3/Guidance Counselor