STUDENT COMPLAINT INTAKE

CASE # (HR STAFF ONLY)

FORM

PRIMARY INFORMATION
Student Name Student I.D.#
Subject & Year Date & Time

When and where did this incident happen? [Specify date & time, location/s- Room#, etc.]

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Who is/are involved in this incident? [other than you: check which applies]

 Fellow students: how many: _________  Teacher/s  Others: ________

Mention names:

STUDENT’S NARRATIVE
(Kindly narrate comprehensively to the best of your ability as to what exactly happened)

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 ENDORSEMENT (TOP RANK STAFF only WITH INITIAL)

Endorsed to
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NAME & SIGNATURE OF ENDORSEE
Position/Office Date & Time
Nature [Reason/s]:

EVALUATION/ RECOMMENDATION ENDORSEE ONLY (valid only with signature)

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Signature Designation
Attachment/s

PRESCRIBED AND APPROVED COURSE OF ACTION AUTHORIZED OFFICER ONLY (valid only with signature)

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Signature Designation
Date & Time
IMPLEMENTATION AUTHORIZED OFFICER ONLY (valid only with signature)
RESPONSIBLE PERSONNEL TO IMPLEMENT APPROVED ACTION
Expected Date of Implementation When Implemented
Witnesses: (at least three including the Complainant)

WITNESS 1 NAME & SIGNATURE WITNESS 2 NAME & SIGNATURE WITNESS 3 NAME & SIGNATURE
Remarks:

Approved by