Republic of the Philippines

Department of Education
REGION IX- ZAMBOANGA PENINSULA
SCHOOLS DIVISION OF DIPOLOG CITY
COGON NATIONAL HIGH SCHOOL
COGON, DIPOLOG CITY
OFFICE OF THE GUIDANCE ADVOCATE

COGON NATIONAL HIGH SCHOOL

INCIDENT REPORT

Date of Incident: __________________________________________________________________________

Time of Incident: __________________________________________________________________________
Location of Incident: _______________________________________________________________________
Person(s) Involved:
Name: ______________________________________________________________________________
Age: ________________________________________________________________________________
Grade Level: _________________________________________________________________________
Gender: _____________________________________________________________________________
Contact Information (phone, email, etc.): __________________________________________________
Relationship to School (student, staff, parent, etc.): __________________________________________
Nature of Incident: _________________________________________________________________________
Description of Incident: _____________________________________________________________________
Witnesses (if any):
Name: _______________________________________________________________________________
Age: _________________________________________________________________________________
Grade Level: __________________________________________________________________________
Gender: ______________________________________________________________________________
Contact Information (phone, email, etc.): ___________________________________________________
Relationship to School (student, staff, parent, etc.): __________________________________________
Actions Taken:
Immediate Actions Taken: _______________________________________________________________
Follow-up Actions Taken: _______________________________________________________________
Recommendations: ________________________________________________________________________
Signature of Reporting Person: ____________________________
 Republic of the Philippines
Department of Education
REGION IX- ZAMBOANGA PENINSULA
SCHOOLS DIVISION OF DIPOLOG CITY
COGON NATIONAL HIGH SCHOOL
COGON, DIPOLOG CITY
OFFICE OF THE GUIDANCE ADVOCATE

COGON NATIONAL HIGH SCHOOL

INCIDENT REPORT

Incident Details:

Date and time of incident

Location of incident
Names of individuals involved
Description of the incident
Witness Information:

Name of witnesses, if any

Contact information for witnesses
Description of what the witness saw or heard
Student Information:

Name and student ID number of the student involved

Grade level and age of the student
Contact information for the student and their parent/guardian
Incident Description:

Detailed description of the incident

Any actions taken by the guidance office staff during or after the incident
Any injuries or damage that occurred during the incident
Follow-up Actions:

Any actions taken by the guidance office staff to address the incident
Any disciplinary action taken against the student involved
Any counseling or support provided to the student or witnesses
Any additional measures taken to ensure the safety of students and staff
Signatures:

Signature of the staff member who completed the incident report

Signature of the student involved (if applicable)
Signature of the parent or guardian of the student involved (if applicable)
Note: It's important to ensure that all information in the incident report is accurate, objective, and factual.
The incident report should be kept confidential and only shared with authorized personnel.

Regenerate response

[Date]

To Whom It May Concern:

I am writing to refer [student's name], a [grade level] student in our school, regarding an incident that
occurred outside of the school premises on [date of the incident].

As a guidance counselor, I have been informed of the situation and have spoken with the student involved. It
is my understanding that [brief summary of the incident]. While this incident occurred outside of school
hours and off school grounds, we believe it is important to notify the barangay office of this situation as it
may have an impact on the student's academic and personal well-being.

I am therefore requesting your assistance in addressing this matter and providing any necessary support and
guidance to [student's name]. I am also available to provide any additional information or assistance that
may be needed to help resolve this situation.

Thank you for your attention to this matter.

Sincerely,

[Guidance Counselor's Name]

[School Name]