Republic of the Philippines

Department of Education
Region VI-Western Visayas
DIVISION OF SAGAY CITY
School: ________________________________________________________________________District: ____________________
REPORT ON CASES OF ABUSE, VIOLENCE, EXPLOITATION, DISCRIMINATION, BULLYING OR PEER ABUSE AND OTHER RELAT
AS OF DECEMBER 31, 2017

Date/Place Nature of Bullying Name of Perpetrator

of Name of Victim Age Sex /Position or relation to Age
Incident Gender- Cyberbullyi victim
Physical Social Retaliation
based ng

Submitted by:
________________________________________
Signature Over Printed Name
________________________________________
Position/Designation

Noted:
_________________________________________
ccd School Head

Republic of the Philippines

Department of Education
Region VI-Western Visayas
DIVISION OF SAGAY CITY
School: ________________________________________________________________________District: ____________________
REPORT ON CASES OF ABUSE, VIOLENCE, EXPLOITATION, DISCRIMINATION, BULLYING OR PEER ABUSE AND OTHER RELA
AS OF DECEMBER 31, 2017

NATURE OF ABUSE Name of Person

Date of
Name of Victim Age Sex Complained of /Position Age
Incident or relation to victim
Physical Sexual Verbal/Psychological Others
 Submitted by:
________________________________________
Signature Over Printed Name
________________________________________
School Head (Designation)

Noted:
ccd
 Form 1 BULLYING
OR PEER ABUSE AND OTHER RELATED OFFENSES

Sex Actions Taken Recommendation Status

_______________________________
ture Over Printed Name
_______________________________
Position/Designation

_________________________________________
PSDS

Case Form 2 CHILD ABUSE

G OR PEER ABUSE AND OTHER RELATED OFFENSES

Sex Actions Taken Recommendation Status (Resolved/pending/Referred to

other Agencies)
_______________________________
ture Over Printed Name
_______________________________
ool Head (Designation)

Noted:
_________________________________________
PSDS