INCIDENT REPORT FORM

TYPE OF INCIDENT

2 Guardians accidently slipped on the ground during the distribution of modules.

INCLUSIVE DATE AND TIME OF INCIDENT

April 22, 2022 around 8:00 and 11:00 in the morning.

EXACT LOCATION OF INCIDENT

In front of Extension V – Room 1

INVOLVED PERSONS & SPECIFIC PARTICIPATION

Marilou Noble, 62 years old, female, guardian of Cymoon N. Jamandre.
Dalhia Apostol, 52 years old, female, mother of Anamae M. Apostol

NARRATIVE DETAILS OF INCIDENT

Mrs. Marilou Noble accidentally slipped on the ground during the distribution of modules last
April 22, 2022 at around 8:00 in the morning while Mrs. Dalhia Apostol also slipped on the same date
at around 11:00 in the morning. Due to heavy rains yesterday afternoon, April 21, 2022, the ground
became slippery that caused minor accidents.

ACTION/S TAKEN
Requested Mr. Ruben Alaban to remove the slippery moss on the ground in front of my
classroom, Extension V - Room 1.

RECOMMENDATIONS
Pathway should be fixed and concretized.

REPORTED BY: DATE RECEIVED:

RENALY JOY L. ESCOBAR, Teacher I

REVIEWED BY: RECEIVED BY:

LEAH ROSE C. CERBO, HTV Mathematics

 LETTER OF REQUEST

September 7, 2022

ERLE P. ARBADO
Principal II, OIC – Office of the Principal IV
Doña Hortencia Salas Benedicto National High School

Sir:

Good day!

May we request that the outer wall of our rooms in Extension IV be repainted. The paint on the said building
has already been worn out and painting will also cover the cracks caused by recent earthquake.

We are looking forward for your positive response to this request. Thank you so much. God bless you!

Respectfully yours,

ILENE M. MONTALVO

RENALY JOY L. ESCOBAR

STEPHEN DELA CHINA

LORENA O. ABAÑO