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    Intake Sheet - Template

    Uploaded by

    chari cruzman
    This intake sheet template is used by the Department of Education Region I Schools Division Office in Pangasinan, Philippines. It collects confidential information about (1) the victim(s), (2) complainant(s), and (3) the person complained of or perpetrator(s). For each party, it requests names, dates of birth, contact details, and relationship information. It also has sections to document the details of the case, any actions taken, and recommendations. The completed form is prepared by a guidance counselor or designate, noted by the school head, and submitted to the Schools Division Office.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Intake Sheet - Template

    Uploaded by

    chari cruzman
    758 views4 pages
    This intake sheet template is used by the Department of Education Region I Schools Division Office in Pangasinan, Philippines. It collects confidential information about (1) the victim(s), (2) complainant(s), and (3) the person complained of or perpetrator(s). For each party, it requests names, dates of birth, contact details, and relationship information. It also has sections to document the details of the case, any actions taken, and recommendations. The completed form is prepared by a guidance counselor or designate, noted by the school head, and submitted to the Schools Division Office.

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    INTAKE SHEET - TEMPLATE.docx

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    This intake sheet template is used by the Department of Education Region I Schools Division Office in Pangasinan, Philippines. It collects confidential information about (1) the victim(s), (2) complainant(s), and (3) the person complained of or perpetrator(s). For each party, it requests names, dates of birth, contact details, and relationship information. It also has sections to document the details of the case, any actions taken, and recommendations. The completed form is prepared by a guidance counselor or designate, noted by the school head, and submitted to the Schools Division Office.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    758 views4 pages

    Intake Sheet - Template

    Uploaded by

    chari cruzman
    This intake sheet template is used by the Department of Education Region I Schools Division Office in Pangasinan, Philippines. It collects confidential information about (1) the victim(s), (2) complainant(s), and (3) the person complained of or perpetrator(s). For each party, it requests names, dates of birth, contact details, and relationship information. It also has sections to document the details of the case, any actions taken, and recommendations. The completed form is prepared by a guidance counselor or designate, noted by the school head, and submitted to the Schools Division Office.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    Republic of the Philippines

    Department of Education
    Region I
    SCHOOLS DIVISION OFFICE I PANGASINAN

    Intake Sheet (template)

    INTAKE SHEET
    (Confidential)

    School : _________________________________________

    Schools District : ___________________________________

    I. INFORMATION

    A. VICTIM/S

    Name : _________________________________________
    Date of Birth : ________________ Age : __________ Sex : __________
    Grade / Year and Section : __________________
    Adviser : _______________________________________

    Parents:
    Mother : ____________________________________
    Occupation : ____________________________________
    Address : ____________________________________
    Contact No. : ____________________________________

    Father : ____________________________________
    Occupation : ____________________________________
    Address : ____________________________________
    Contact No. : ____________________________________

    B. COMPLAINANT/S
    Name : __________________________________________

    Address: Alvear St. Lingayen, Pangasinan 1


    Telephone No.: (075)-522-2202
    Email: [email protected]
    Republic of the Philippines
    Department of Education
    Region I
    SCHOOLS DIVISION OFFICE I PANGASINAN

    Relationship to Victim : __________________________


    Address : ____________________________
    Contact No. : _____________________________
    C. PERSON COMPLAINED OF / PERPETRATOR/S

    C-1 If the Person Complained of is a School Personnel


    (Teaching or Non-Teaching)

    Name : _________________________________________
    Date of Birth : ________________ Age : __________ Sex : _______
    Position / Designation : __________________
    Address : ____________________________
    Contact No. : _____________________________

    C-2 If the Person Complained is a Student

    Name : _________________________________________
    Date of Birth : ________________ Age : __________ Sex : _______
    Grade / Year and Section : __________________
    Adviser : _______________________________________

    Parents:
    Mother : ____________________________________
    Occupation : ____________________________________
    Address : ____________________________________
    Contact No. : ____________________________________

    Father : ____________________________________
    Occupation : ____________________________________
    Address : ____________________________________
    Contact No. : ____________________________________

    Address: Alvear St. Lingayen, Pangasinan 2


    Telephone No.: (075)-522-2202
    Email: [email protected]
    Republic of the Philippines
    Department of Education
    Region I
    SCHOOLS DIVISION OFFICE I PANGASINAN

    C-3 If the Person Complained is an Outsider

    Name : _________________________________________
    Date of Birth : ________________ Age : __________ Sex : _______
    Position / Designation : __________________
    Address : ____________________________
    Contact No. : _____________________________

    II. DETAILS OF THE CASE

    III. ACTIONS TAKEN

    IV. RECOMMENDATIONS

    Prepared By:

    ____________________________ (signature over printed name)


    Guidance Counselor / Guidance Counselor (Designate) Teacher
    Date : _________________

    Noted :

    ____________________________ (signature over printed name)


    School Head
    School : ________________________________
    Schools District : _______________________

    Address: Alvear St. Lingayen, Pangasinan 3


    Telephone No.: (075)-522-2202
    Email: [email protected]
    Republic of the Philippines
    Department of Education
    Region I
    SCHOOLS DIVISION OFFICE I PANGASINAN

    Date : _________________

    Address: Alvear St. Lingayen, Pangasinan 4


    Telephone No.: (075)-522-2202
    Email: [email protected]

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