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ST. JOSEPH SCHOOL OF BALIUAG INC.

J.P. Rizal St., Sta. Barbara, Baliwag, Bulacan


S.Y. 2019 -2020
________________________________________________________________________________________

INCIDENT REPORT FORM

TYPE OF INCIDENT:

INCLUSIVE DATE AND TIME OF INCIDENT :

EXACT LOCATION OF INCIDENT :

INVOLVED PERSON/S & SPECIFIC PARTICIPATION: (Full name, age, gender, position/designation/grade level,
involvement in the incident. Use back page if needed. If there are minors involved, names should be withheld by the School –
Child Protection Specialist)

NARRATIVE DETAILS OF INCIDENT: (Describe how the incident happened, scene of incident, physical and emotional state
of involved persons, description of injuries/damages to properties, impact to class/school/community, etc. Use back page if needed.)

ACTION/S TAKEN : (Narrate responses/decisions implemented by school authorities, state name of official. Use back page if needed.)

RECOMMENDATION/S :

DATE PREPARED : DATE RECEIVED:

PREPARED BY:
_______________________________
Position/Designation
REVIEWED BY: ACKNOWLEDGED BY:

MR. NEMIAS D. SANTOS ______________________________


PREFECT OF DISCIPLINE PRINCIPAL

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