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Intake Sheets

This intake sheet summarizes a case involving a victim, complainant, and respondent. It includes personal information about the victim and their parents. For the complainant, it lists their name and relationship to the victim. There are sections for information about the respondent, whether they are a school personnel or student, as well as their personal details. The document concludes by outlining the details of the case, actions taken, and recommendations.

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Tel Pascua
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996 views2 pages

Intake Sheets

This intake sheet summarizes a case involving a victim, complainant, and respondent. It includes personal information about the victim and their parents. For the complainant, it lists their name and relationship to the victim. There are sections for information about the respondent, whether they are a school personnel or student, as well as their personal details. The document concludes by outlining the details of the case, actions taken, and recommendations.

Uploaded by

Tel Pascua
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DEPARTMENT OF EDUCATION

_____________________SCHOOL

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 the 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. & Section:_____________________________________ Adviser:______________________________________
Parents/Guardians:
Mother:________________________________________________________________ Age:______________________
Occupation:______________________________Address & Contact Number:__________________________________
Father:_________________________________________________________________ Age:______________________
Occupation:______________________________Address & Contact Number:__________________________________

II.Details of the Case

__________________________________________________________________________________________________

III.Action Taken:
1._________________________________________________________________________________________________
2._________________________________________________________________________________________________
3._________________________________________________________________________________________________

IV.Recommendations:
1._________________________________________________________________________________________________
2._________________________________________________________________________________________________

Prepared by:

________________________________________
Signature Over Printed Name

________________________________________
Designation

________________________________________
Date

Noted:

________________________________________
Principal
REPORT ON CASES OF CHILDREN-AT-RISK (CAR)
SY 2017 – 2018

SCHOOL:____________________________________ Period Covered: _________________________


District:_____________________________________

CHILDREN – AT – RISK

No. of Students
Classification Action Taken Remarks
Male Female
1. Victims 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

Description of action taken by the school or division to alleviate the risk factors of the CAR:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Submitted by:

___________________________
School Head

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