Republic of the Philippines

Department of Education
Region III
Schools Division of Zambales
Iba District
BANGANTALINGA ELEMENTARY SCHOOL

CHILD PROTECTION POLICY

ANNEX B (INTAKE SHEET)

I. INFORMATION
A. VICTIM
Name: _________________________________________________________________________
Date of Birth: ___________________ Age:_________________ Sex: ______________
Grade & Section: _____________________________ Adviser: ________________________

Parents

Mother: ____________________________________ Age: _________

Occupation: ________________________________
Address/Contact Number: _______________________________________________________________

Father: ____________________________________ Age: _________

Occupation: ________________________________
Address/Contact Number: ___________________________________________________________________

B. COMPLAINANT

Name: __________________________________________________________________________________
Relationship to the Victim: ________________________________________________________________
Address and Contact Number: _____________________________________________________________

C. RESPONDENT
C.1. If the respondent is a School Personnel

Name: _______________________________________________________________________________
Date of Birth: ___________________ Age:_________________ Sex: ___________________
Address & Contact Number: _______________________________________________________________

C.2. If respondent is a Student

Name: _________________________________________________________________________
Date of Birth: ___________________ Age:_________________ Sex: ______________
Grade & Section: _____________________________ Adviser: ________________________

Mother: ____________________________________ Age: _________

Occupation: ________________________________
Address/Contact Number: _______________________________________________________________

Father: ____________________________________ Age: _________

Occupation: ________________________________
Address/Contact Number: ___________________________________________________________________
II. DETAILS OF THE CASE
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III. ACTION TAKEN

1.______________________________________________________________________________________________
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2.______________________________________________________________________________________________
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3.______________________________________________________________________________________________
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IV. RECOMMENDATIONS:
1.______________________________________________________________________________________________
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2.______________________________________________________________________________________________
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3.______________________________________________________________________________________________
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Prepared by:

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Signature over Printed Name
___________________________________________
Designation
___________________________________________
Date

Noted by:

JOSEPHINE D. LAVILLA, Ed. D.

Principal I
Date: __________________