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Lucena City School Case Intake Form

The document is an intake sheet used by a school governance council to collect information about victims, complainants, and respondents for cases. It requests personal details such as names, ages, occupations and contact information. It also has sections to document details of the case, actions taken, and recommendations.

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308501
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121 views1 page

Lucena City School Case Intake Form

The document is an intake sheet used by a school governance council to collect information about victims, complainants, and respondents for cases. It requests personal details such as names, ages, occupations and contact information. It also has sections to document details of the case, actions taken, and recommendations.

Uploaded by

308501
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
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

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