Republic of the Philippines

Department of Education
Division of Cebu Province
CABONGA-AN ELEMENTARY SCHOOL
Cabonga-an San Francisco, Cebu

INTAKE SHEET

I. INFORMATION
A. VICTIM

Name: ______________________________________ Birthdate: ____________ Age: __________ Sex: _________

Grade/Year Level and Section: __________________ Class Adviser: ___________________________________________

Parents:
Name of Father: ______________________________________________ Occupation: __________ Age: _________
Address: _____________________________________________________ Contact Number: _________________________
Name of Mother: _____________________________________________ Occupation: __________ Age: _________
Address: _____________________________________________________ Contact Number: _________________________

B. COMPLAINANT

Name: ______________________________________ Relationship to the Victim:

_______________________________
Address: _____________________________________________________ Contact Number: _________________________

C. RESPONDENT

C-1. If Respondent is a School Personnel

Name: ______________________________________ Birthdate: ____________ Age: __________ Sex: _________
Designation/Position: ________________________ Address: _____________________ Contact No.: ____________

C-2. If Respondent is a Student

Name: ______________________________________ Birthdate: ____________ Age: __________ Sex: _________
Grade/Year Level and Section: __________________ Class Adviser: ___________________________________________

Parents:
Name of Father: ______________________________________________ Occupation: __________ Age: _________
Address: _____________________________________________________ Contact Number: _________________________
Name of Mother: _____________________________________________ Occupation: __________ Age: _________
Address: _____________________________________________________ Contact Number: _________________________
II. DETAILS OF THE CASE:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
III. ACTION TAKEN
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________
4. _______________________________________________________________________________________
IV. RECOMMENDATIONS
1. _______________________________________________________________________________________
2. _______________________________________________________________________________________
3. _______________________________________________________________________________________

Prepared by:
________________________________
Signature Over Printed Name

________________________________
Designation/Date