Annex “B”
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: _____________
Designation/Position: __________________________________
Address and Contact Number: __________________________________________________
___________________________________________________________________________
___________________________________________________________________________
C-2. If respondent is a Student
Name: ________________________________________________
Date of Birth: __________________ Age: ________Sex: __________
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:
IV. RECOMMENDATIONS:
Prepared By: _____________________________
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