Department of Education

Region 02
Division of Isabela
Mabini National High School
Mabini, Gamu, Isabela

INCIDENT REPORT FORM

LOCATION INFORMATION

Date of this report: January 22, 2018

Parish/School or Institution: Mabini National High School

Address: 3301, Zone 6, Mabini, Gamu, Isabela, Philippines

Person Reporting Incident: Jojielyn B. Bilog

Phone number: 09752759220 Email: jojiebautistabilog@gmail.com

Date of accident: December 27, 2017 Time: 1 o’clock PM

Injured Person was: Student / Volunteer / Parishioner ___ / Other ________

Name of Injured Person: Glevelyn A. Lacerna Age: 57 y/o

Address: Mabini, Gamu, Isabela

Birthday: October 29, 1960

Phone Number(s): 0926-342-3255

Injury requires physician/hospital visit? Yes _____ / No______

Was Ambulance called? Yes _____ / No______

Who called the ambulance? Brgy. Captain Glimerson Laverinto

Treatment received: _____ First Aid ______ Doctor ______ Hospital

Name of physician:June R. Malana, M.D.

Name of Hospital/Address: Baligatan Doctors Medical Hospital, Baligatan, City of Ilgan, Isabela

Where did Accident Occur? Mabini National High School Ground

Were photos taken? Yes / No ____

Type of Injury: Bimalleolar Fracture (Left Foot)

Result of Accident: Plating (Inplant of Diskplate)

Witnesses:

Mrs. Myline J. Respicio Mabini NHS HTIII/OIC 09163931455

Mr. Jess Anthony Agcaoili Event Sports Coordinator 09175593344
Mr. Marlo Lucas Mabini NHS Faculty President 09163467919

Prepared by:

JOJIELYN B. BILOG
Secretary, MNHS Alumni Association

NOEL L. ABAYA
President, MNHS Alumni Association

Noted by:

MYLINE J. RESPICIO
HT III/ OIC, MNHS