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ANECDOTAL RECORD

NAME OF LEARNER:_________________________________________LRN:________________
Grade & Section:________________________________ School Year:_____________________

DATE INCIDENT AGREEMENT/ACTION TAKEN SIGNATURE OF


PERSON’S INVOLVED

Prepared by:

CHESTER L. CABANA
Class Adviser

Submitted to:

CHRISTINE CIMAGALA
School Guidance Coordinator

Noted by:
HELEN C. TANASAS, PhD
Principal I

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