STUDENT’S INCIDENT REPORT
(POD Form 1 for Minor Offenses)
Name
Grade and
Section
 Absenteeism, cutting of classes and
tardiness
 Failure to wear prescribed uniform
 Wearing of cap and the like inside the
school building specially inside the
classroom
 Wearing of earrings for the boys and
more than a pair of earrings for the
I was girls, outlandish hairstyles, painting of
tattoo, over accessories and body
 INVOLVED IN
piercing
 ACCUSED OF  Using profane language to insult
another / Cursing
 Littering
 Using different gadgets during class
hour
 Public display of affection (PDA)
 Unruly behavior during assemblies,
religious services, etc.
WHAT HAPPENED? (Indicate your side)
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Date
Class
Adviser
 Refusal to display school ID
prominently and placing stickers and
other objects on school ID
 Sitting on tables, standing on benches
as sitting with feet up and legs wide
apart
 Writing or drawing on a fellow
student’s books and notebooks.
 Borrowing without returning
 Irresponsibly playful like pulling chair
away when one is about to sit; hiding
another’s property; blocking another’s
path, etc
 Putting make-up and face powder
during class hour
 Bullying including physical, emotional,
mental and cyber-bullying
 Voyeurism and other indecent acts
(To be filled up after the conversation with the Prefect of Discipline and the Teacher)

AGREEMENT
After being admonished by the Prefect of Discipline and my Class Adviser (or my Subject
Teacher), I, __________________________________________, promise to:

1) ________________________________________________________________

2) ________________________________________________________________

3) ________________________________________________________________

I understand that this agreement serves as a WARNING and that failure to comply with
the resolutions I made and agreed with the Prefect of Discipline and my Class Adviser (or
my Subject Teacher) will have my PARENTS BE CALLED at school.

_____________________________________________
Student’s Printed Name and Signature
Date: _________________________

_____________________________________________
Class Adviser’s Name and Signature

_____________________________________________
Grade Level Prefect of Discipline

Noted by:

MA. CECILIA CARPIO RIMAS

Grade 8 Level Guidance Teacher

CARLA MHAIE BERSAMINA PABILLONA

Grade 8 Level Academic Coordinator

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