INCIDENT REPORT FORM

Office/SDO/School: BARIIS INTEGRATED SCHOOL Incident Report No. _______________

(i.e.ROV Admin-GSU/Legazpi City/Albay Central School) Case Code No.-Year (i.e.CPI 001-2022)

TYPE OF INCIDENT Death of a grade 6 Pupil due to electric shock

Specify the incident i.e. fire, vehicular accident, armed conflict,
robbery, for Child Protection Issues, specify per DO 40, s. 2012

DATE OF INCIDENT December 31, 2023

TIME OF INCIDENT 6:00 p.m.

PLACE/EXACT LOCATION Purok 4 - Cawalog, Bariis, Legazpi City

OF INCIDENT

PERSONS INVOLVED & THEIR A male pupil of Bariis Integrated School who is currently
SPECIFIC PARTICIPATION (Indicate full enrolled in grade 6 – Diamond.
name, age, gender, position/designation/grade level,
involvement in the incident. Names of minors should be
withheld; use of alias is suggested. Use an additional
sheet if needed)

DESCRIPTION/DETAILS OF THE An ambulance passed by Bariis Centro around 6:30 in the

INCIDENT (Describe/narrate how the incident afternoon of December 31, 2023. A hearsay was heard that the
happened, sustained injuries, damages incurred,
emotional state of the involved persons, impact to the
ambulance had a 12-year old boy who suffered electric shock
school/workplace/community. Use additional sheet if and will be brought to BRTTH.
needed with page number)

By 10 a.m. of January 1, 2024, a casket with the body of

the said boy was brought to its home at Cawalog, Bariis,
Legazpi City. Some residence said that the said boy is a grade 6
pupil of Bariis Integrated School.

Ma’am Lolita A. Araña, the schoolhead instructed the grade

6 teachers to confirm the issue. Upon the home visit, it was
confirmed that the victim is a grade 6 – Diamond pupil of Bariis
Integrated School.

The said incident brought much pain and sadness to the

school especially to his classmates.

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ACTIONS TAKEN (State the responses/initial On the first day of school CY 2024, the teachers and pupils
actions taken, decisions made or implemented by the
school authorities or immediate supervisors)
offered a prayer led by Ma’am Araña for the soul of the departed
pupil. In addition, she reminded the pupils to observe safety
precautions at all times in an out the school premises.

To lessen the burden/sadness felt by the grade 6 pupils, their

adviser conducted emotional support activities and stress
debriefing.

The school gave financial support to the bereaved family.

FOLLOW UP The bereaved family is need of financial support.

RECOMMENDATIONS (State suggestions
that other concerned DepEd Officials/Offices must
consider or must do to fully respond to the situation)

PREPARED BY NAME/POSITION/DESIGNATION/CONTACT NUMBER

JENIFER L. SAMAR/ Teacher III/ Class Adviser/CP #:09093204948

DATE PREPARED JANUARY 3, 2024
RECEIVED & REVIEWED BY (Should NAME/POSITION/DESIGNATION/CONTACT NUMBER
be the Designated Information Officer)
MARY ROSE A. LERON/ Teacher III/ School Info. Officer/ CP#:09487500675
DATE/TIME RECEIVED JANUARY 4, 2024
NOTED BY NAME/SDS/ASDS/CONTACT NUMBER

Data Privacy Notice: In compliance to the Data Privacy Act of 2012, the data collected in this form shall be confidential
and shall be processed according to the DepEd Data Privacy Policy and FOI and shall not be shared to any third/external
party without the approval of the Regional Director and the Secretary of the Department of Education.

ROV/ORD-PAU/mmlj
Copyright 2022
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