Republic of the Philippines

Department of Education
SCHOOL GOVERNANCE COUNCIL
REGION IV-A CALABARZON
SCHOOLS DIVISION OF LUCENA CITY
308501 LUCENA DALAHICAN NATIONAL HIGH SCHOOL
Purok Bagong Silang, Brgy. Dalahican, Lucena City, Quezon, Philippines

Intake Sheet
INFORMATION
A.VICTIM:
Case No.: _________________
Name: _____________________________ Date of birth: ________________ Age: _______
Sex: _________ Gr./Yr. and section: _____________ Adviser: _______________________
Parents: Mother: ________________________ Age: _____ Occupation: _______________
Address and Contact Number _______________________________________________
Father: _______________________________ Age: _____ Occupation: ________________
Address and Contact Number: ________________________________________________

B. COMPLAINANT:
Case No: ____________________
Name: ____________________________________ Relationship to Victim: ____________
Address and Contact Number: _______________________________________________

C. RESPONDENT:
1.If respondent is a School Personel
Case No: ______________________
Name: ________________________________ Date of Birth: ____________ Age: _______
Sex: __________ Gr./Yr. and Section: ____________ Adviser: _______________________

2.If respondent is a Student

Case No: ______________________
Name: ____________________________ Date of Birth: ________________ Age: _______
Sex: _________Gr./Yr. and Section: _______________ Adiviser: _____________________
Parents/Guardian: Mother: _____________________ Age: ____ Occupation: ___________
Address and Contact Number: ________________________________________________
Father: _______________________________ Age: ____ Occupation: _________________
Address and Contact Number: ________________________________________________

II. DETAILS OF THE CASE:

________________________________________________________________________________
III. ACTION TAKEN:
________________________________________________________________________________
IV. RECOMMENDATIONS:

Prepared by:
_________________________________________ ____________ _____________
Signature over Printed Name/Designation Date Time

Noted By:
___________________________________________ ____________ _____________
Signature over Printed Name/Designtion Date Time

Lucena Dalahican National High School

Purok Bagong Silang, Brgy. Dalahican, Lucena City, Quezon, Philippines
Tel. #: (042) 784- 2026 Cel. #: 09533581515 / 09620805032
E-mail: 308501@deped.gov.ph