(Enclosure No. 1A 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 Report on Incidents of Bullying

School Year 2019-2020
October, 2019
School: Pacita Complex Senior High School
(Stand Alone SHS No. 19 San Pedro) Classification: (Private/Public) Public
Address: Tirad Pass St. Pacita Complex, San Pedro, Laguna Level: Secondary

Nature of Bullying Victims Perpetrator Status

Date/Place Physica Social Gender Cyber Retaliation Name Age Sex Name Age Sex Action Recommendatio (Resolved/Pendin
of Incident l -Based Bullying M/F M/F Taken n g/ Referred to
other agency)
NONE

Note: Bullying is perpetrated by a student against another student which may be:
 Physical- unwanted physical contact (punching, shoving, pushing, kicking, slapping, tickling, 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 exclude a person’s 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.)

Prepared by:
REZALIE G. NEPOMUCENO
School Guidance Designate

Date: October 31, 2019

Reviewed and Conformed by:

JOVITO M. BARCENAS, PhD

Public Schools District Supervisor/OIC-Principal

Date: October 31, 2019