Republic of the Philippines

Department of Education
Region X-Northern Mindanao
Division of Cagayan de Oro
LAPASAN NATIONAL HIGH SCHOOL
Lapasan, Cagayan de Oro City

Student Accident/Incident Report

PERSONAL DETAILS OF THE STUDENT

Full Name: Anthony Julius T. Razalo

Date of Birth: August 04, 2006
Age: 13
Name of Parent/Guardian: Genievev Timbal (mother)
Address: San Juan 2, Lapasan, Cagayan de Oro City
Contact Number: n/a

ACCIDENT DETAILS

Date of injury: November 12, 2019

Time: 11 am
Location of accident: Grade 7 – Angel Jeremiel Classroom
Describe the injuries sustained by the student: Head injury
State exactly what happened: During their English class, the students were busy practicing
for their Jazz Chant presentation. However, there were some students who were just playing
during that time. Unfortunately, Anthony Julius T. Razalo was pushed by one of his
classmates. He accidentally hit his head on a steel chair which resulted to a head injury. He
was immediately brought to the school clinic by his class adviser.
Was first aid given by the school? Yes/No Was further medical attention given? Yes/No
Name of hospital: J.R. Borja Memorial City Hospital

Prepared by: Noted by:

VON KRIZTIAN XAM M. LOREJO GILJUN T. PENULIAR

Class Adviser Secondary School Principal I