NORTH 1- DISTRICT

DALIPUGA NATIONAL HIGH SCHOOL

DALIPUGA, ILIGAN CITY
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INCIDENT REPORT FORM

TYPE OF INCIDENT:

INCLUSIVE DATE AND TIME OF INCIDENT:

EXACT LOCATION OF INCIDENT: ( Room, Building, Area, School, Sitio, Barangay, Municipality
etc)

INVOLVED PERSONS & SPECIFIC PARTICIPATION : ( Full Name, Age, Gender, Position,
Designation, Grade Level & Section, Involvement in the incident. Use back page if needed)

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

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

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

REPORTED BY: ( Full name,Position, DATE RECEIVED:

Designation and Signature)

REVIEWED BY: ( Full name, RECEIVED BY:

Position,Designation and Signature)

__________________________________________________________________________________

Address: Dalipuga, Iligan City

Telephone No.: (063) 225-2798
Email: dalipuganationalhighschool@gmail.com