Republic of the Philippines
Department of Education
REGION XI
DIVISION OF DAVAO DEL NORTE
LIMBAAN NATIONAL HIGH SCHOOL
Limbaan, New Corella, Davao del Norte
INCIDENT REPORT FORM
TYPE OF INCIDENT
INCLUSIVE DATE AND TIME OF INCIDENT
EXACT LOCATION OF INCIDENT: (room, building, area, school, sitio, barangay, municipality, etc.)
INVOLVED PERSONS & SPECIFIC PARTICIPATION: (Full name, age, gender, position/designation/grade level,
involvement in the incident. Use back page if needed)
NARRATIVE DETAILS OF INCIDENT: (Describe how the incident happened, scene of incident, physical and
emotional state of involved persons, description of injuries/damages to properties, impact to class/school/community, etc. Use
back page if needed.)
ACTION/S TAKEN: (Narrate responses/decisions implemented by school authorities, state name of official. Use back page
if needed.)
RECOMMENDATIONS: (State suggestions that higher DepEd officials/other government agencies must perform further to
fully respond to situation. Use back page if needed.)
REPORTED BY:
The recipient of herein report acknowledges the NAME: _______________________________
confidentiality hereof and shall prevent the
unauthorized disclosure of certain proprietary POSITION: ____________________________
and confidential information stated above
VERIFIED BY:
***Must be submitted within 24 hours from time of
occurrence. NAME: TOMOTEO T. CAPADNGAN
POSITION: SCHOOL HEAD
