(Enclosure No. 1A to Deped Memorandum No. 59, s.

2015)
Annex "A"

Report of cases of abuse, violence, exploitation, discrimination, bullying or peer abuse and other related offenses

School/Division/Region: Sapangdaku Elementary School

Period Covered: June -March
Person Submitting Report: _____________________ Designation: _____________Date: ______________

Victim/s Respondent/s

SEX (M
Name AGE SEX (M or F) NAME AGE NATURE OF COMPLAINT ACTION/S TAKEN RECOMMENDATION/S
or F)
 (Enclosure No. 1B to Deped Memorandum No. 59, s. 2015)

School-Based Report on Incidents of Child Abuse

School Year ___________

School: SAPANGDAKU ELEMENTARY SCHOOL Classification: (Private/Public) _

Address: Sapangdaku , Cebu City Level: (Kindergarten/Elementary/Secondary)

Date of Nature of Abuse Victims Perpetrators Relationship Action Status

Incident to the victim taken (Resolved/Pending/
Referred to other
agency)

Physical Sexual Verbal/P (Last Name, First Age Sex (Last Age Sex
sycholog Name, M.I.) (M/F) Name, (M/F)
ical First
Name,
M.I.)

Total
Note:
* Child Abuse refers to the maltreatment of a child, whether habitual or not, which includes any of the following:
Physical- refers to acts that inflict bodily harm & which subjects children to perform tasks which are harzardous to their
 (Enclosure No. 1A to Deped Memorandum No. 59, s. 2015)

School-Based Report on Incidents of Child Bullying

School Year ________________

School: SAPANGDAKU ELEMENTARY SCHOOL Classification: Public

Address: Sapangdaku , Cebu City Level: Elementary

Date/ Place Nature of Abuse Victims Perpetrator Action taken Recommendation

of Incident Status
(Resolved/Pendi
ng/ Referred to
other agency)

Physical Social Gender Cyber Retallia Name Age Sex Name Age Sex
Based Bullying tion (M/F (M/F
) )
Note: Bullying is pertrated by a student against another student which maybe:
Physical- unwanted physical contact (punching, shoving, pushing, kicking, slapping, tickling, headlocks etc.)
Social- refers to any deliberate, repetitive and aggressive social behavior intended to hurt or belittle an individual (name-calling, cursing, labelling. Etc.)
Gender-Based- refers to nay act that humiliates or excludes a person on the basis of perceived or actual sexual orientation and gender identity
Cyber Bullying- any bullying done through the use of technology or nay electronic means (texting, email, chatting, online games etc.)

Reviewed and Conformed by: Prepared by:

Date: Date: