Enclosure A-1
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:
1.
2.
3.
4.
IV. RECOMMENDATIONS:
1.
2.
3.
Prepared By:
_____________________________
Name over Printed Name
_____________________________
Designation
_____________________________
Date
Enclosure A-2
Appendix A
Profiling and Initial Risk Assessment Tools for Children-at-Risk
PART I:
This form will help the guidance teacher or guidance counselor quickly note down risk factors that
make the child vulnerable to coming into conflict with the law. A check mark on those items in
red/bold font require immediate referral of the child to the LSWDO, DSWD or licensed child-caring
agencies and NGOs for further assessment and treatment or intervention planning.
A mark on the other items or factors, other than those in red, require further investigation or data
gathering on the part of the school CPC before referral is made to the LSWDO or DSWD.
Initial assessment made using this form will not substitute for the professional assessment and
judgment of a licensed counselor, licensed child psychologist and licensed social worker.
I. Child’s Identifying Information
Name: ____________________________________________________________________________
Age: ________________
Date of Birth: ________________________
Sex: ________________
Address: __________________________________________________________________________
In School?
Caregivers:
____ Yes;
Grade/Year Level: ____________
____ No;
Highest grade/year level finished: _________________
____ Father only
____ Mother only
____ Father and Mother
____ Others(indicate relationship to child): _________________________________
Caregiver’s source of income/employment and monthly income: _____________________________
No. of Siblings: _________
Ordinal Position: ___________
No. of Siblings below 18 yrs. Old: _______________
Appendix A
II. Individual factors:
_____ History of substance/Alcohol abuse
_____ Involvement in gangs
_____ Involvement in any positive youth development activity, identify: _______________________
_____ Reported incidents of sudden outbursts of anger/irritability exhibited in school
_____ Report or allegations of traumatic experience of the child
_____ Reported recent suicide attempts or suicidal ideation
_____ Child observed in class to be depressed, anxious and out of focus most of the time
_____ Constant somatic complaints
_____ Reported/Noted thoughts disturbances
Types of offenses committed (Mark with X and indicate how many times reported for every type of
offense committed)
_______________ Theft
_______________ Robbery
_______________ Physical injuries
_______________ Sexual harassment
_______________ Rape
_______________ Homicide
_______________ Murder
_______________ Drug-related offense
_______________ Other offenses punished under penal laws (please indicate)
Family/community factors:
_____ Child is a victim of abuse, identity ________________ (sexual, physical, emotional, verbal)
_____ Child is a victim of neglect
_____ Child has no parents or no adult guardian in the household
_____ History of parental criminal behavior
_____ History of sibling’s criminal behavior
_____ Witness to family/domestic violence
_____ Parent substance abuse
_____ Homeless
_____ Abandoned
_____ Witness to community violence
_____ Presence of support system (family, community, church, school)
School behavior
_____ Child is behaving well in school
_____ Child is a victim of bullying in school
_____ Child has been observed to have moderate behavior problems in school
_____ Child had severe problems with behavior in school. Child has been reported for bullying in
school.
Juvenile Justice (JJ)
History of criminal behavior
_____ Current criminal behavior is the first known occurrence
_____ Youth has engaged in multiple delinquent acts in the past year
Seriousness
_____ Youth has engaged only in status violations or violations of local ordinances
_____ Youth has engaged in criminal behavior
_____ Youth has engaged in criminal behavior that places other citizens at risk of significant physical
harm
Peer Influences
_____ Youth’s primary peer social network does not engage in delinquent behavior
_____ Youth predominantly has peers who engage in delinquent behavior
_____ Youth’s primary peer social network are known to engage in criminal behavior
_________________________________
Indicators were based on the Juvenile Justice Module of the Child and Adolescent Needs and
Manual. Preda Foundation (1999)
Strengths
Appendix A
PART II:
The table below further provides a non-exhaustive list of examples of evidence which would
suggest that a student has met the threshold for an immediate referral to the proper authorities
(LSWDO, Licensed SW of accredited and duly-licensed child caring agency, or to the DSWD CIU) or
whether there is still a need for further investigation or data gathering on the allegations before
referrals are made.
Initial assessment made using this form will not substitute for the professional assessment and
judgment of a licensed counselor, licensed child psychologist and licensed social worker.
Referral to LSWDO for immediate intervention within 8 hours
Initial Assessment: For further investigation before referral to LSWDO or DSWD within 24 hours
Any allegation of abuse or neglect or any
suspicious injury in a non-mobile child
Allegation of physical assault with no
visible injury (child is mobile and verbal)
Two or more minor injuries in non-verbal
young children (including disabled
children)
Allegations or suspicions about a serious
injury
Any incident/injury triggering concern
e.g. a series of apparently accidental
injuries or a minor non-accidental injury
Allegations or suspicions about a sexual
abuse perpetrated against a child
Repeated allegations or reasonable
suspicions of non-accidental injury or
injuries
The child has been traumatized, injured
or neglected as a result of domestic
violence
Repeated allegations involving serious
verbal threats and/or emotional abuse
Repeated expressed minor concerns
from one or more sources on suspicions
on non-accidental injury
Allegation concerning verbal threats
Allegations of emotional abuse including
that caused by minor domestic violence
Appendix A
Allegations/reasonable suspicions of
serious neglect
Direct allegation of sexual abuse made by
child or abuser’s confession to such
abuse
Any allegation suggesting connections
between sexually abused children in
different families or more than one
abuser.
Allegations of periodic neglect including
insufficient supervision; poor hygiene; clothing
or nutrition; failure to seek/attend treatments
or appointments; young carers undertaking
intimate personal care.
Suspicions of sexual abuse (e.g. medical
concerns, sexualized behavior, or referral
by concerned relative, neighbor and
caregiver)
An individual inside the child’s home
posing a risk to the child (alleged
perpetrator living with the child or who
has daily access to the child/adult alleged
of threatening child to commit crime,
etc.)
Any suspicious injury or allegation
involving a child already subject to a child
protection plan or looked after by a local
authority.
No Available parent/carer and child is left
abandoned child
Suspicion that a child has suffered or is at
risk of significant harm due to
fabricated/induced illness.
A child reported to be at-risk of sexual
exploitation of trafficking
Pregnancy in a child
No available parent, child in need of
temporary accommodation and no
specific risk if this needs is met
Appendix A
A child at risk of forced marriage
Initial assessment made by:
____________________________________
Name and Signature
_________________________
Designation
Noted By:
____________________________________
Name and Signature
_________________________
Designation
Enclosure A-3
Appendix B
Children in Conflict with the Law (CICL) Intake Form
Division: __________________
Region: __________________
Name of School: _________________________________________________________
Address: _______________________________________________________________
Case. No: _____________________
Date: ________________________
I. Identifying Information
Name: _____________________________________________________________
Nickname: __________________
Age: ___________
Sex: _________________
Date of Birth: _____________________
Place of Birth: _____________________
Address: ____________________________________________________________
Grade/Year Level & Section: ____________________________________________
Class Adviser: ________________________________________________________
Parents/Guardian Information:
Parents/Guardian: ____________________________________________________
Address: ____________________________________________________________
Contact No’s: ________________________________________________________
II. Problem Presented (Information on the Reported Offense)
Alleged offense committed by the student (describe incident as reported):
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Place and Date of Alleged Commission of Offense: _________________________________________
Name of referring party/relation to the child: ____________________________________________
Name of victim/s (if any): _________________________________ Grade/Level: ________________
Previous Offense reported in school, if any (please indicate date):
__________________________________________________________________________________
Appendix B
III. Actions Taken, if any
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
IV. Disposition:
Referred and/or Released to:
LSWDO Name: ___________________________
Contact No: ___________________
PNP Name: ______________________________
Contact No: ___________________
NGO/FBO Name of Organization: ________________________________________________
Contact No: ___________________
Released to:
Parents
Guardian
Relative/s Name: ________________________________ Contact No: __________________
____________________________________
Name and Signature of Receiving Copy
Address: ________________________________________________
Prepared by:
________________________________
Name and Signature
_________________________
Designation
Noted by:
________________________________
Name and Signature
_________________________
Designation
Enclosure A-4
Appendix C
REFERRAL FOR SERVICE
Instructions
This form should be completed by fully trained and designated staff of the
school. Original copy shall be maintained in the school and shall form part
of the client’s confidential records.
Any information contained herein and the rest of the records of the client
shall be held in strict confidence. No information from this card shall be
shared to anyone except to service provider and as may be authorized.
Attach additional pages with continued narrative, if needed.
Case No: _________________
To: _______________________________________________________________________________
Address: __________________________________________________________________________
Contact Person: ____________________________________________________________________
Name of Student: ___________________________________________________________________
Age: __________
Sex: _________
Address: ___________________________________
Reason/s for Referral:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Specific Service/s Requested:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Please refer to attached report/ intake form /case summary for more information.
Appendix C
Feedback is requested. Please send to:
Referring Party/School: ______________________________________________________________
Address: __________________________________________________________________________
Cellphone No: ____________________
Landline No: ________________________________
E-mail Address: ______________________________ Fax No: _____________________________
Contact Person: ____________________________________________________________________
Referred by:
____________________________________
Signature over Printed Name
____________________________________
Date Accomplished
______________________________
Designation
Enclosure A-5
Appendix E
RESTORATIVE JUSTICE AGREEMENT FORM
I. Background of the Incident
II. Statement of Agreement
For the best interest of (name of offender) and the school/community, the following shall be
undertaken:
For the student-offender:
(Example: make a research work on the ill-effects of smoking)
__________________________________________________________________________________
__________________________________________________________________________________
For the parents of the student-offender:
__________________________________________________________________________________
__________________________________________________________________________________
For the teacher-adviser/Guidance Counselor or Guidance Teacher:
__________________________________________________________________________________
__________________________________________________________________________________
For the social worker or Local Social Welfare and Development Officer (LSWDO):
__________________________________________________________________________________
__________________________________________________________________________________
For the victim and his/her parent/s (when appropriated):
__________________________________________________________________________________
This agreement will be implemented starting _________________ until ___________________.
Prepared by:
_____________________________________
Guidance Counselor/RJP Secretary
Conformed:
_________________________ ________________________
(Student-offender)
(Parent)
Noted by:
________________________________
Principal/RJP Chairperson
____________________________
LSWDO/Social Worker
Enclosure A-6
School-Based Report on Incidents of Bullying
School Year: ________________
School: _______________________________________
Address: _____________________________________
Classification: (Private/Public) __________________________________
Level: (Kindergarten/Elementary, Secondary) ______________________
Nature of Bullying
Date/Place of
Incident
Physical
Social
Gender- Cyber
Retaliation
Based Bullying
Victims
Name
Age
Perpetrator
Sex
(M/F)
Name
Age
Sex
(M/F)
Action
taken
Status
(Resolved/Pending/
Recommendation
Referred to other
agency)
Note: Bullying is perpetrated by a student against another student which may be:
 Physical-unwanted physical contact (punching, shoving, pushing, kicking, slapping, tickling, headlocks, etc.)
 Social-refers to any deliberate, repetitive and aggressive social behavior intended to hurt or belittle an individual (name-calling, cursing, labelling, etc.)
 Gender-based – refers to any act that humiliates or excludes a person on the basis of perceived or actual sexual orientation and gender identity.
 Cyber Bullying – any bullying done through the use of technology or any electronic means (texting, email, chatting, online games, etc.)
Reviewed and Conformed by:
_____________________________
Name and Designation
Date:
______________________
Prepared by:
_____________________________
Name/Designation
Date:
__________________________
Enclosure A-7
School-Based Report on Incidents of Child Abuse
School Year: _____________
School: _______________________________________
Address: ______________________________________
Date of
Incident
Nature of Abuse
Verbal/
Physical Sexual Psychologic
al
Classification: (Private/Public) ___________________________
Level: (Kindergarten/Elementary, Secondary) _______________
Victims
Name
(Last Name,
First Name, M.I)
Age
Sex
(M/F)
Perpetrators
Name
(Last Name,
Age
First Name, M.I)
Sex
(M/F)
Relationship
to the Victim
Action
Taken
Status
(Resolved/Pending/R
eferred to other
agency)
TOTAL
Note:
Child Abuse refers to the maltreatment of a child, whether habitual or not, which includes any of the following:
 Physical-refers to acts that inflict bodily harm and which subjects children to perform tasks which are hazardous to their physical well-being;
 Sexual-refers to acts that are sexual in nature such as rape, sexual harassment, sexually demeaning remarks, forcing children to watch obscene publications or
shows, etc.; and
 Psychological – refers to acts or omissions causing or likely to cause mental or emotional suffering to the child which include intimidation, harassment, stalking,
public ridicule, threat of deduction from grade or merit as a form of punishment, and repeated verbal abuse.
-
Relationship to the victim refers to relatives (father, mother, cousin, etc.) or school personnel (teachers and non-teaching staff)
No amicable settlement for any acts of child abuse
Reviewed and Conformed by:
___________________________________
Name and Designation
Date: ______________________________
Prepared by:
_____________________________________
Name/Designation
Date: ________________________________
Enclosure A-8
Appendix D
CONSOLIDATED REPORT ON CASES OF CHILDREN-AT-RISK (CAR)
School/Division/Region: _________________________________
Period Covered: _________________________________
I. CHILDREN-AT-RISK (CAR)
Classification
No. of Students
Male
Female
Action Taken
Remarks
1. Victim of Abuse (sexual, physical,
psychological, mental, economic,
and other mean)
2. Victim of Neglect
3. Coming from a dysfunctional
family or without parent or guardian
4. Being member of a gang
5. Living in a community with a
higher level of criminality
6. Living in a situation of armed
conflict
7. Committed a status Offense
under Section 57 of RA 9344, as
amended
8. Prostituted Children
9. Mendicant under PD 1563
10. Solvent/Rugby User
11. Others
II. Description of action taken by the school or division to alleviate the risk factors of the CAR:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Prepared by:
Noted by:
________________________
Designation
____________________________________
Principal/Superintendent/Regional Director
Enclosure A-9
Appendix F
School/Division/Region: __________________________________
Period Covered: ________________________________________
A. Consolidated Report on incidents of Children in Conflict with the Law (CICL)
Learner’s
Sex
Reference Number
Age
Case/Violation
Action Taken
(M/F)
(LRN)
Intervention/Diversion
Program
Remarks
B. Description of any intervention program or diversion program that the school or division initiated or adapted which facilitated the reintegration of
the CICL in the school and community
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Prepared by:
Noted by:
_______________________________________
Designation
_______________________________________
Principal/Superintendent/Regional Director
Enclosure A-10
SCHOOL-BASED CHILD PROTECTION/ANTI-BULLYING POLICY IMPLEMENTATION CHECKLIST
(Based on Annex 2B of DepEd Order No. 44, s.2015: Guidelines on the Enhanced School Improvement Planning (SIP)
Process and the School Report Card (SRC))
Name of School: _________________________________________
Address: _______________________________________________
Schools District: _________________________________________
Schools Division: _________________________________________
Date of Submission: _____________________________________
Instruction: This checklist is designed to monitor and evaluate the compliance of the school in the implementation of
DepEd Order No. 40, s. 2012 and DepEd Order No. 55, s. 2013
Tick the appropriate box that corresponds to your observation
P – Present or In Place
A – Absent or Not In Place
Findings will be based simply on the presence or absence of the requirement as stated in each item and shall be the
basis for a plan of action by the school and the Schools Division Office.
P
1. The school has a written school-based child protection and/or anti-bullying policies
2. There is a code of conduct incorporated in the school-based child protection or anti-bullying
policy for the following:
a) Students
b) School Administrators
c) Non-Teaching Personnel (guards, maintenance, etc.)
d) Teachers
e) Visitors (Parents, Alumni, etc.)
f) Off-Campus activities such as field trips, camping’s, etc.
3. The code of conduct has specific provisions to address potential risks to students such as:
a) Disregarding abusive situation or behavior against children;
b) Employing children as house helper or asking students to care for
teacher’s children while in school;
c) Relating with children in private for personal matters like studentteacher as “text mates” or Facebook friends;
d) Going out with students after school such as watching movies;
e) Using green jokes or jokes with double meaning in the class; and
f) Cultural beliefs (marrying children because it is acceptable based on
one’s culture/religion, amicable settlement on child abuse cases)
4. Promotion or information dissemination of the school-based child protection and/or antibullying policies is done during school opening for:
a) Students
b) Teachers
c) Non-Teaching Personnel
d) Parents
5. There are written procedures to guide in conducting disciplinary proceedings in cases of
offenses committed by pupils, students, or learners.
6. The School has adopted a conflict resolution mechanism that respects the rights of indigenous
peoples, provided that they conform to child’s rights and the Department issuances on child
protection.
7. There is an established system for identifying students who may be suffering from significant
harm based on physical, emotional, or behavioral signs.
A
8. Has developed and implemented a school-based referral and monitoring system to address
child abuse and bullying cases.
9. There is an existing record of all proceedings related to bullying and child abuse cases using
the Intake Sheet (Annex B of DO 40, s. 2012 or Appendix B of DO 18, s. 2015) as appropriate.
10. Records related to complex cases of child abuse and bullying using the Intake Sheets (Annex A
of DO 40, s. 2012 or Appendix B of DO 18, s. 2015) are well-kept and separate from simple
cases.
11. The school has submitted its consolidated reports on bullying and child abuse cases to the
Division Office a week after the opening of each school year.
12. Has mapped out available resources in their community for possible linkages or networking
for cases needing referrals, etc.
13. Has an active coordination with WPCD, DSWD, and other government and Non-Government
Organizations (NGO).
14. Has a clear policy on the use of positive and non-violent discipline for children.
15. There is an organized Child Protection Committee (CPC) in the school.
16. There is an annual capacity building activities for the members of the CPC:
a) Guidance Counselor/Designated Guidance Teacher
b) Representative of the Students
c) Representative of the Parents
d) Representative of the Barangay
e) Representative of the Teachers
17. The CPC is meeting regularly to discuss appropriate interventions and/or responses to school
problems on bullying and child abuse cases and other concerns.
18. The school with its CPC has initiated information dissemination programs and organized
activities for the protection of children from abuse, exploitation, violence, harm, and bullying.
19. There is a strong student participation in the promotion of child protection and anti-bullying
policies of the school.
20. There is a feedback mechanism in the school to monitor the implementation of the Child
Protection and/or Anti-Bullying policies.
Respectfully Submitted:
_________________________________________________
Signature above Printed Name of School Head
Enclosure B-1
DIVISION CONSOLIDATED REPORT ON INCIDENTS OF BULLYING
SCHOOL YEAR ______________
(Based on Enclosure 2A of DepEd Memorandum No. 59, s. 2015)
Division: __________________
Total Number of Public Schools: ________
Elementary: ________
Secondary: _________
Total: ________
School
Physical
M
I.
Public
A. Elementary
1.
2.
Sub-Total
(Public Elementary):
B. Secondary
1.
2.
Sub-Total
(Public Secondary)
II.
Private
A. Kindergarten
1.
2.
Sub-Total
(Private Kindergarten)
B. Elementary
1.
2.
Sub-Total
(Private Elementary)
C. Secondary
1.
2.
Sub-Total
(Private Secondary)
Total:
F
Total Number of Private Schools: ________
Elementary: _________
Secondary: __________
Total: ________
Nature of Bullying
Gender
Cyber
Social
-Based Bullying
M
F
M
F
M
F
Retaliation
M
F
No. of Bullying Incidents
Total
Total
No. of No. of
Total
Male Female
Victims Victims
Note: Bullying is perpetrated by a student against another student, which may be:
 Physical-unwanted physical contact (punching, shoving, pushing, kicking, slapping, tickling, headlocks, etc.)
 Social-refers to any deliberate, repetitive and aggressive Social behavior intended to hurt or belittle an
individual (name-calling, cursing, labelling, etc.)
 Gender-Based – refers to any act that humiliates or excludes a person on the basis of perceived or actual
sexual orientation and gender identity.
 Cyber Bullying-any bullying done through the use of technology or any electronic means (texting, email,
chatting, online games, etc.).
Prepared by:
Reviewed and Conformed by:
____________________________
Name and Designation
_______________________________
Name and Designation
____________________________
Date
_______________________________
Date
Enclosure B-2
DIVISION CONSOLIDATED REPORT ON INCIDENTS OF CHILD ABUSE
SCHOOL YEAR ______________
(Based on Enclosure 2B of DepEd Memorandum No. 59, s. 2015)
Division: __________________
Total Number of Public Schools: ________
Elementary: ________
Secondary: _________
Total: ________
School
Nature of Abuse
Verbal/
Physical Sexual
Psychological
M
I.
Public
A. Elementary
1.
2.
Sub-Total
(Public Elementary)
B. Secondary
1.
2.
Sub-Total
(Public Secondary)
II.
Private
A. Kindergarten
1.
2.
Sub-Total
(Private Kindergarten)
B. Elementary
1.
2.
Sub-Total
(Private Elementary)
C. Secondary
1.
2.
Sub-Total
(Private Secondary)
Total:
Total Number of Private Schools: ________
Elementary: _________
Secondary: __________
Total: ________
F
M
F
M
F
No. of Incidents of Child Abuse
Total
Total
No. of
Perpetrators
No. of
Total
Male
Female
Incidents
Victims
Victims
Note:
Child Abuse refers to the maltreatment of a child, whether habitual or not, which includes any of the following:
 Physical-refers to acts that inflict bodily harm and which subjects children to perform tasks which are
hazardous to their physical well-being;
 Sexual-refers to acts that are sexual in nature such as rape, sexual harassment, sexually demeaning remarks,
forcing children to watch obscene publications or shows, etc.; and
 Psychological – refers to acts or omissions causing or likely to cause mental or emotional suffering to the
child which include intimidation, harassment, stalking, public ridicule, threat of deduction from grade or
merit as a form of punishment, and repeated verbal abuse.
-
Relationship to the victim refers to relatives (father, mother, cousin, etc.) or school personnel (teachers and
non-teaching staff)
No amicable settlement for any acts of child abuse
Prepared by:
Reviewed and Conformed by:
_________________________________
Name and Designation
___________________________________
Name and Designation
_________________________________
Date
___________________________________
Dat
Enclosure B-3
Division Consolidated Reports on the Submission of School-Based Child Protection or Anti-Bullying Policies (As of
July 2014)
Division: __________________
Total Number of Public Schools: ________
Elementary: ________
Secondary: _________
Total: ________
Name of School
Total Number of Private Schools: ________
Elementary: _________
Secondary: __________
Total: ________
School I.D.
School-Based
Child Protection
Policy with AntiBullying Policy
Policy Submitted
School-Based
Child Protection
Policy without
Anti-bullying
Policy
Antibullying
Policy Only
I. Public
A. Public
1.
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
TOTAL:
B. Secondary
1.
II. Private
A. Kindergarten
1.
B. Elementary
1.
C. Secondary
1
Instruction:
1. * Put a check (√) on the kink pf policy the school has submitted. Choose one.
2. Get the total no. of policy submitted per category. (Ex. Total No. of School Base-Based Protection with AntiBullying Policy submitted by Public Elem.)
Prepared by:
______________________________
Designation
______________________________
Date
Reviewed and Conformed by:
_______________________________
Designation
_______________________________
Date
Enclosure B-4
DIVISION CONSOLIDATED REPORT ON CHILD-FRIENDLY SCHOOLS BASED ON CHECKLIST
Division: _____________________
School Year: ____________________
Date of Submission: _______________________
No.
Name of School
Kindergarten/Elementary (Total Number of Schools:
_______)
1.
2.
3.
4.
5.
High School (Total Number of Schools: _______)
1.
2.
3.
4.
5.
Sub-Total: _____
GRAND TOTAL: _____
Submitted by:
________________________________
Signature over Printed Name
________________________________
Designation
Perfect Score
(37)
High Score
(28-36)
Scores Below
(27)