Republic of the Philippines

DEPARTMENT OF EDUCATION
Region V
DIVISION OF CAMARINES SUR
San Jose, Pili, Camarines Sur
SAN RAMON HIGH SCHOOL
Bula, Camarines Sur

INTAKE SHEET
I. INFORMATION
A. VICTIM
Name: ______________________________________
Date of Birth: ________________________________ Contact Number: __________Age: ____ Sex: ____
Gr./Yr. and Section: ___________________________ Adviser: __________________________________

Name of Parents/Guardian
Mother: _____________________________________ Age: __________ Occupation: _______________
Address: ____________________________________

Father: ______________________________________ Age: __________ Occupation: _______________

Address: ____________________________________

B. COMPLAINT
Name: ______________________________________ Contact Number: __________________________
Relationship to the Victim: _____________________ Address: _________________________________

C. RESPONDENT
C-1. If respondent is a School Personnel

Name: ______________________________________ Contact Number: __________Age: ____ Sex: ____

Date of Birth: ________________________________ Designation: _______________________________

C-2. If respondent is a Student

Name: ______________________________________ Contact Number: __________Age: ____ Sex: ____

Date of Birth: ________________________________ Address: __________________________________
Gr./Yr. & Section:_____________________________ Adviser: __________________________________

Name of Parents/Guardian
Mother: _____________________________________ Age: __________ Occupation: _______________
Address: ____________________________________

Father: ______________________________________ Age: __________ Occupation: _______________

Address: ____________________________________

II. DETAILS OF THE CASE

III. ACTIONS TAKEN

1. ___________________________________________________________________________________________
2. ___________________________________________________________________________________________
3. ___________________________________________________________________________________________

IV. RECOMMENDATIONS
1. ___________________________________________________________________________________________
2. ___________________________________________________________________________________________
3. ___________________________________________________________________________________________

Prepared by: Noted:

_________________________________________________ ___________________________________
Name and Signature Over Printed Name of Reporting Officer Guidance Counsellor/Prefect of Discipline