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Intake Sheet - Template

This intake sheet template is used by the Department of Education Region I Schools Division Office in Pangasinan, Philippines. It collects confidential information about (1) the victim(s), (2) complainant(s), and (3) the person complained of or perpetrator(s). For each party, it requests names, dates of birth, contact details, and relationship information. It also has sections to document the details of the case, any actions taken, and recommendations. The completed form is prepared by a guidance counselor or designate, noted by the school head, and submitted to the Schools Division Office.

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8K views4 pages

Intake Sheet - Template

This intake sheet template is used by the Department of Education Region I Schools Division Office in Pangasinan, Philippines. It collects confidential information about (1) the victim(s), (2) complainant(s), and (3) the person complained of or perpetrator(s). For each party, it requests names, dates of birth, contact details, and relationship information. It also has sections to document the details of the case, any actions taken, and recommendations. The completed form is prepared by a guidance counselor or designate, noted by the school head, and submitted to the Schools Division Office.

Uploaded by

chari cruzman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Republic of the Philippines

Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN

Intake Sheet (template)

INTAKE SHEET
(Confidential)

School : _________________________________________

Schools District : ___________________________________

I. INFORMATION

A. VICTIM/S

Name : _________________________________________
Date of Birth : ________________ Age : __________ Sex : __________
Grade / Year and Section : __________________
Adviser : _______________________________________

Parents:
Mother : ____________________________________
Occupation : ____________________________________
Address : ____________________________________
Contact No. : ____________________________________

Father : ____________________________________
Occupation : ____________________________________
Address : ____________________________________
Contact No. : ____________________________________

B. COMPLAINANT/S
Name : __________________________________________

Address: Alvear St. Lingayen, Pangasinan 1


Telephone No.: (075)-522-2202
Email: pangasinan1@[Link]
Republic of the Philippines
Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN

Relationship to Victim : __________________________


Address : ____________________________
Contact No. : _____________________________
C. PERSON COMPLAINED OF / PERPETRATOR/S

C-1 If the Person Complained of is a School Personnel


(Teaching or Non-Teaching)

Name : _________________________________________
Date of Birth : ________________ Age : __________ Sex : _______
Position / Designation : __________________
Address : ____________________________
Contact No. : _____________________________

C-2 If the Person Complained is a Student

Name : _________________________________________
Date of Birth : ________________ Age : __________ Sex : _______
Grade / Year and Section : __________________
Adviser : _______________________________________

Parents:
Mother : ____________________________________
Occupation : ____________________________________
Address : ____________________________________
Contact No. : ____________________________________

Father : ____________________________________
Occupation : ____________________________________
Address : ____________________________________
Contact No. : ____________________________________

Address: Alvear St. Lingayen, Pangasinan 2


Telephone No.: (075)-522-2202
Email: pangasinan1@[Link]
Republic of the Philippines
Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN

C-3 If the Person Complained is an Outsider

Name : _________________________________________
Date of Birth : ________________ Age : __________ Sex : _______
Position / Designation : __________________
Address : ____________________________
Contact No. : _____________________________

II. DETAILS OF THE CASE

III. ACTIONS TAKEN

IV. RECOMMENDATIONS

Prepared By:

____________________________ (signature over printed name)


Guidance Counselor / Guidance Counselor (Designate) Teacher
Date : _________________

Noted :

____________________________ (signature over printed name)


School Head
School : ________________________________
Schools District : _______________________

Address: Alvear St. Lingayen, Pangasinan 3


Telephone No.: (075)-522-2202
Email: pangasinan1@[Link]
Republic of the Philippines
Department of Education
Region I
SCHOOLS DIVISION OFFICE I PANGASINAN

Date : _________________

Address: Alvear St. Lingayen, Pangasinan 4


Telephone No.: (075)-522-2202
Email: pangasinan1@[Link]

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