REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF EDUCATION
REGION XII
City of Koronadal, Philippines
Telefax No. (083) 228-8825; email:region12@deped.gov.ph

INCIDENT REPORT

Enclosure 1 to Region Memo 2015: Incident Report

Initial Incident Report (signed report due within 24-hr)

Site: Incident Register Number:
Division:

Location of Incident: Date and Time of Incident:

Type of Incident:
Injury Environment Suspension of Classes Security School Property/Equipment
Safety – Type of Injury (if applicable): Environment:
First Aid Injury Restricted Work Injury 1 Negligible 4 Serious
Lost Time Injury Other Medical Treat Injury 2 Minor Disastrous 5 Disastrous 3
Significant
DepEd Employee Students and Teachers
Brief Description of Incident:
Class suspension of the above mentioned Municipalities due to heavy rain.
Preliminary findings/Causes of incident:
Actual Consequences (injuries / environment / property equipment / financial impact/administrative or legal
liability):

Potential Consequences (injuries / environment / property equipment / financial impact/administrative or legal

liability):

Person(s) Involved:
None

Name(s) of Witness(es):

Initial Action(s) Taken:

LGU Declaration

Level of Incident (potential or actual consequence weighting, whichever is higher): Statutory Notification:
Safety & Health 1 2 3 4
Yes No
Environment 1 2 3 4 5 Division RO XII
School Property / Equipment 1 2 3 4 Central Others
_______
Legal Context
Is legal advice necessary? Does the incident qualify as an Does the incident or administrative
Yes (contact DepED Legal Team immediately) administrative case*? case have potential civil or criminal
No Yes liability?
No Yes (contact DepEd Legal Team
immediately)
No
Media Attention:
Regional Director School Division Superintendent Supervisor

ALLAN G. FARNAZO, CESO IV

Investigation Team: (if required)

Prepared by: R Algarme/S Sato Status: Approved Issue date: May 9, 2012 Next review date: On event of change Page: 2 of 2

Approved by: C Pocknee Version: 2.0 Effective date: May 10, 2012 Document owner: SDC

Unless stamped in RED, this is an ‘Uncontrolled Document’