Republic of the Philippines

Department of Education
Region VII
CANDUMAN ELEMENTARY SCHOOL
Canduman, Mandaue City, Cebu

INCIDENT REPORT FORM

TYPE OF INCIDENT
Kicking

INCLUSIVE DATE AND TIME OF INCIDENT

October 14, 2022 / 9:20 am (Snacks Time)

EXACT LOCATION OF INCIDENT: (room, building, area, school, sitio, barangay, municipality, etc.)
Inside the Grade One-Love Classroom

INVOLVED PERSONS & SPECIFIC PARTICIPATION: (Full name, age, gender, position/designation/grade level,
involvement in the incident. Use back page if needed)
 Stacey Margaret S. Antiporta, 6, years old girl
 David Luis S. Herbito, 6 years old boy

NARRATIVE DETAILS OF INCIDENT: (Describe how the incident happened, scene of incident, physical and emotional
state of involved persons, description of injuries/damages to properties, impact to class/school/community, etc. Use back page if
needed.)

During recess time, while I was on my laptop to prepare the presentation for the next class, David suddenly cried telling me that
Stacey kicked his right hand. As per the investigation, David was reportedly sticking his tongue out toward Stacey. Stacey is seated at the back of
David. David was twisting his head, was not seated properly, and was facing Stacey to start a chitchat. Stacey must have been annoyed of David’s
action, which led her to kick David’s hand.

ACTION/S TAKEN: (Narrate responses/decisions implemented by school authorities, state name of official. Use back page if
needed.)

The Teacher conduct a dialogue between the two pupils. It was reiterated that all forms of violence or
physical harms incurred are not justifiable for whatever reasons. Both pupils were transferred to a different seat with a
hope to improve behavior and performance in the classroom.

RECOMMENDATIONS: (State suggestions that higher DepEd officials/other government agencies must perform further to fully
respond to situation. Use back page if needed.)

 Anger Management practices in the classroom

 Parents’ Conference

REPORTED BY: (Full name, position/designation and signature) DATE RECEIVED: (to be accomplished by SGOD staff)
ANA MARIE V. CATAMCO

REVIEWED BY: (Full name, position/designation and signature) RECEIVED BY: (to be accomplished by SGOD staff)

MARY JEAN C. SENO