DEPARTMENT OF EDUCATION
INTAKE SHEET
I.
INFORMATION
A. VICTIM:
Name:___________________________________________________________________
Date of Birth:____________________________________Age:_________Sex:_________
Gr./ Yr. and Section:_______________________Adviser:__________________________
Parents:
Mother:_________________________________________________Age:_________
Occupation:___________________________________________________________
Address:______________________________________________________________
Father:__________________________________________________Age:_________
Occupation:___________________________________________________________
Address and Contact Number:____________________________________________
B. COMPLAINANT:
Name:___________________________________________________________________
Relationship to Victim:______________________________________________________
Address and Contact Number:_______________________________________________
C. RESPONDENT:
C – 1. If respondent is a School Personnel
Name:_______________________________________________________________
Date of Birth:________________________________ Age:_________Sex:_________
Address and Contact Number:____________________________________________
C – 2. If respondent is a Student
Name:_______________________________________________________________
Date of Birth:________________________________ Age:_________Sex:_________
Address and Contact Number:____________________________________________
Gr./ Yr. and Section:_____________________Adviser:_________________________
Parents/ Guardian:
Mother:_________________________________________________Age:_________
Occupation:___________________________________________________________
Address and Contact Number:____________________________________________
Father:__________________________________________________Age:_________
Occupation:___________________________________________________________
Address and Contact Number:____________________________________________
II. DETAILS OF THE CASE
III. ACTION TAKEN
1.
2.
3.
IV. RECOMMENDATIONS:
1.
2.
3.
Prepared by:
___________________________________
Name over Printed Name
___________________________________
Designation
___________________________________
Date