Form-Report On Incidents of Bullying

(Enclosure No.1 to DepEd Memorandum No. 68,s.
2014)
(To be submitted to the Division Office on or before July 3)
REPORT on INCIDENTS of BULLYING and RETALIATION
School Year 2017-2018
School I.D. 307111
School : Josephine F. Khonghun Special Education Center
Address: Brgy. Wawandue, Subic, Zambales
Classification: Public
Level: Secondary Grade & Section: Grade Ten Pascal Month: March 2017
Date of the
NATURE* VICTIMS RESPONDENTS SCHOOL
Incident Status
Cyber- NAME Sex NAME Sex Action
(mm/dd/yyyy) Physical Psychological Retaliation*** Age Age Recommendation (Resolved,Unresolved
Bullying (Last,First Name,M.I.) (M/F) (Last,First Name,M.I.) (M/F) Taken
Pending)
*Put a check (/) on the nature of bullying incident or retaliation.

**Retaliation refers to any act against a person who reports bullying,who provides information during an investigation of bullying,or who is a witness to or has reliable information about bullying(RA 10627)
*** Status Resolved – both the victim and the student offender/respondent have undergone intervention program
Pending – the incident is pending investigation, victim or the student offender/respondent is still undergoing intervention program
Unresolved – failed to conduct investigation or intervention; no action
Prepared by:
LULU BELLE B. PADRIQUE
Teacher III
Date: _______________
Reviewed and Conformed by:
_________________________
Date:____________________
(Enclosure No.1 to DepEd Memorandum No. 68,s.2014)
School I.D. 160513
Level: Elementary Grade & Section: Grade One-Marlowe Month: July 2016
Date of the
Incident Status
Pending)

Prepared by:
LIEZEL F. FERIDO
Master Teacher I
Date: _______________
_________________________
Date:____________________
School I.D. 160513
Level: Elementary Grade & Section: Grade Two-Twain Month: August 2016
Date of the
Incident Status
Pending)

Prepared by:
JENIFFER A. GONZALES
Teacher II
Date: _______________
_________________________
Date:____________________
School I.D. 160513
Level: Elementary Grade & Section: Grade Two-Lewis Month: July 2016
Date of the
Incident Status
Pending)

Prepared by:
ZAIRENE MARIE G. SALAVEDRA
SPED Teacher I
Date: _______________
_________________________
Date:____________________
School I.D. 160513
Level: Elementary Grade & Section: Grade Three-Austen Month: July 2016
Date of the
Incident Status
Pending)

Prepared by:
ANALYN C. DELA CRUZ
Master Teacher I
Date: _______________
_________________________
Date:____________________
School I.D. 160513
Level: Elementary Grade & Section: Grade Three-Milton Month: July 2016
Date of the
Incident Status
Pending)

Prepared by:
RUBY ANN MARCIA
SPED Teacher I
Date: _______________
_________________________
Date:____________________
School I.D. 160513
Level: Elementary Grade & Section: Grade Four-Hugo Month: July 2016
Date of the
Incident Status
Pending)

Prepared by:
MARY ANNE C. ANGELES
Master Teacher II
Date: _______________
_________________________
Date:____________________
School I.D. 160513
Level: Elementary Grade & Section: Grade Five-Andersen Month: November 2016
Date of the
Incident Status
Pending)

Prepared by:
CATHERINE A. PANOY
Master Teacher I
Date: _______________
_________________________
Date:____________________
School I.D. 160513
Level: Elementary Grade & Section: Grade Six-Shakespeare Month: August 2016
Date of the
Incident Status
Pending)

Prepared by:
LOVELY DIOSA D.BATNAG
Teacher I
Date: _______________
_________________________
Date:____________________
School I.D. ___________
Level: Secondary Grade & Section: Grade Seven- Einstein Month: July 2016
Date of the
Incident Status
Pending)

Prepared by:
JOAN LAT GARCIA
Teacher I
Date: _______________
_________________________
Date:____________________
School I.D. ___________
Level: Secondary Grade & Section: Grade Eight- Newton Month: July 2016
Date of the
Incident NAME Status
Cyber- NAME Sex Sex Action
(mm/dd/yyyy) Physical Psychological Retaliation*** Age (Last,First Age Recommendation (Resolved,Unresolved
Bullying (Last,First Name,M.I.) (M/F) (M/F) Taken
Name,M.I.) Pending)

Prepared by:
HONEYLYN TOLENTINO
Teacher I
Date: _______________
_________________________
Date:____________________
School I.D. __________
Level: Secondary Grade & Section: Grade Nine-Mendeleev Month: July2016
Date of the
Incident Status
Pending)

Prepared by:
__________________________
Teacher I
Date: _______________
_________________________
Date:____________________
School I.D. 307111
Level: Secondary Grade & Section: Grade Ten- Pascal Month:
Date of the
Incident Status
Pending)

Prepared by:
LULUBELLE PADRIQUE
Teacher I
Date: _______________
_________________________
Date:____________________
(To be submitted to the Division Office on or before July 3,2014)
School I.D. 160513
Level: Kinder
(To be submitted to the Division Office on or before July 3,2014)
School I.D. 160513
Level: Secondary

Form-Report On Incidents of Bullying

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Form-Report On Incidents of Bullying

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(Enclosure No.1 to DepEd Memorandum No. 68,s.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

*Put a check (/) on the nature of bullying incident or retaliation.

(To be submitted to the Division Office on or before July 3,2014)

REPORT on INCIDENTS of BULLYING and RETALIATION

School Year 2016-2017

School I.D. 160513

School : Josephine F. Khonghun Special Education Center

Address: Brgy. Wawandue, Subic, Zambales

(To be submitted to the Division Office on or before July 3,2014)

REPORT on INCIDENTS of BULLYING and RETALIATION

School Year 2016-2017

School I.D. 160513

School : Josephine F. Khonghun Special Education Center

Address: Brgy. Wawandue, Subic, Zambales

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