GOF FORM 001

INTAKE SHEET

CASE NO: ___________________

DATE OF FILLING:__________________

I. INFORMATION
A. If it is a violation of School Code of Conduct: ________________________
B. If there is a victim
VICTIM: NAME:
Date of Birth:
Age :
Sex :
Year and Section:
Adviser:
PARENTS: Mother’s Name:
Age :
Occupation:
Address:
Father’s Name:
Age :
Occupation:
Address:
C. COMPLAINANT: NAME:
Position :
(If there is a victim only) Relation to Victim :
Address:
Contact Number:
D. RESPONDENT : D-1 If respondent is a School Personnel
Name:
Date of Birth :
Age:
Sex:
Designation /Position:
Address :
Contact No:
D-2 If respondent is a Student
Name:
Date of Birth :
Age:
Sex:
Year and Section:
Adviser :
PARENTS: Mother’s Name:
Age :
Occupation:
Address:
Father’s Name:
Age :
Occupation:
Address:
II. DETAILS OF THE CASE

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III. ACTION TAKEN

1. ________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

4. ________________________________________________________________

5. ________________________________________________________________

IV. RECOMMENDATION
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Prepared by:

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Signature Over Printed Name

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Designation

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Date